DEA-254 CSOS Certificate Application Registrant List Addendum

Instructions for completing DEA Form 254
CSOS Certificate Application Registrant List Addendum
Introduction:
Form DEA-254 is for individuals requesting to be enrolled for more than one DEA Registration
number in the CSOS program. This Addendum form must be associated with a Registrant
(DEA-251), Coordinator (DEA-252) or Power of Attorney (DEA-253) Certificate Application.
Approved Registrant, Coordinator (if requesting the ability to sign controlled substance orders),
and Power of Attorney applicants will be issued a CSOS Signing Certificate for each location
listed on his/her application and associated addendums. Coordinator Applicants who have not
requested signing authority will be issued only one CSOS Administrative Certificate, but will be
authorized fulfill the role of Coordinator for all DEA Registration Numbers listed on his/her
application and associated addendums.
Bulk Enrollment:
Up to five (5) Registrant List Addendums listing a total of 50 DEA Registration Number(s) may
be submitted with a Registrant, Coordinator, or Power of Attorney Certificate Application.
Please contact DEA Diversion E-Commerce Support if applying with more than 50
Registrations.
Completing the application:
The information must be TYPED electronically into the PDF form with the exception of
signatures, affirmations and the notary acknowledgement sections, which must be completed in
blue or black ink. All fields must be completed.
Registrant and Coordinator Applicants must include a photocopy of the DEA Registration
Certificate (form DEA-223) for each DEA Registration Number indicated on the Registrant List
Addendum.
Section 1 – Applicant Information (All fields required)
Field Name
Applicant Last Name
Applicant First Name
MI
Applicant Social
Security Number
Addendum _ of _

Information Description
Enter the last name of the applicant.
Enter the first name of the applicant.
Enter the middle initial of the applicant. Enter ‘X’ if the applicant
does not have a middle initial.
Enter the Social Security Number of the applicant. This information
will be kept private and used for internal purposes as stated in the
Privacy Policy.
Enter the page number of the addendum form and the total number of
addendum forms included for the applicant. Example: 1 of 3, 2 of 3, 3
of 3.

Please contact DEA Diversion E-Commerce Support for enrollment assistance.
Phone: 1-877-DEA-ECOM (1-877-332-3266)
E-mail: [email protected]

Instructions for completing DEA Form 254
CSOS Certificate Application Registrant List Addendum
Section 2 – DEA Registration List
Field Name
DEA Registration
Num

DEA Registration
Name

Information Description
Enter the DEA Registration Number(s) for which the applicant will
be responsible. The number(s) entered on the application MUST
appear as it does on the registrant’s DEA Registration Certificate
(Form DEA-223). Inconsistency between the application and the
registration will result in approval delays or denial.
Enter the name of the DEA Registered location(s) as it appears on
the registrant’s DEA Registration Certificate (Form DEA-223).
Inconsistency between the application and the registration
certificate will result in approval delays or denial.

Section 3 – Applicant/Notary Signature (all fields required)
Field Name
Applicant
Signature, Date
Notary Signature,
Date

Information Description
The applicant must sign and date the application using blue or black
ink IN THE PRESENCE of a certified notary public. The party
signing this application must be the same party listed in Section 1
– Applicant Information (First Name/Last Name/MI).
Registrant and Coordinator Applicants - A CERTIFIED
NOTARY PUBLIC must sign the Registrant List Addendum(s)
attached to the Certificate application using blue or black ink.
Power of Attorney Applicants – The CSOS Coordinator must sign
the Registrant List Addendum(s) attached to the Power of Attorney
Certificate Application using blue or black ink.

Warning: When the applicant signs the application, he/she is stating that he/she has read,
understood, and agreed to abide by the rules and regulations contained in the Controlled
Substance Ordering System Subscriber Agreement and Certificate Policy. He/she is certifying
that the information, statements and representations provided by him/her on the application are
true and accurate to the best of his/her knowledge. He/She understands that presenting false
information is a criminal offense and is punishable by law. Section 843(a)(4)(A) of Title 21,
United States Code, states that any person who knowingly or intentionally furnishes false or
fraudulent information in the application is subject to imprisonment for not more than four years,
a fine of not more than $30,000.00 or both.
In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a collection
of information unless it displays a valid OMB control number. The OMB control number for the
collection of this information is 1117-0038. Public reporting burden for this collection of information is
estimated to average 1.5 hours, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information.

Please contact DEA Diversion E-Commerce Support for enrollment assistance.
Phone: 1-877-DEA-ECOM (1-877-332-3266)
E-mail: [email protected]

Form DEA-254

(Expires: July 31, 2022)

Approved OMB
NO.1117-0038

CSOS Certificate Application Registrant List Addendum
CSOS Certificate applicants shall complete this addendum to identify additional DEA Registrants for which a CSOS Certificate shall be issued. A CSOS
Certificate application must accompany this addendum.

Section 1 – Applicant Information
Applicant Last Name

Applicant First Name

MI

Applicant SSN Number

Addendum

Of

Section 2 – DEA Registrant list
DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

Section 3 –– Applicant/Notary Signature
Applicant Signature ______________________________________________________________________ Date __________
This form will be denied and returned if not signed and dated by the applicant listed in Section 1 of this form.

Notary/CSOS Coordinator Signature ________________________________________________________ Date __________
This form must be signed and dated by the Notary Public who notarized the accompanying Form DEA-251 (for Registrants) or DEA-252 (for Coordinators).
Alternately, if applying as a CSOS Power of Attorney with accompanying form DEA-253 (for CSOS POA's), this Addendum form must be signed and dated by
the applicant's CSOS Coordinator.