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Drug Registration
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DEA Form 363 Instructions
DEA FORM 363
NEW APPLICATION FOR REGISTRATION
NARCOTIC TREATMENT PROGRAMS
INSTRUCTIONS
SECTION
1.
APPLICANT
IDENTIFICATION - Information must be typed or printed in the
blocks provided to help reduce data entry errors. A physical
address is required in address line; a post office box or
continuation of address may be entered in address line 2. Fee exempt
applicant must list the address of the fee exempt
institution. The email address and point of contact are new data
items that are in the process of OMB approval and will be soon
be mandatory. They are requested in order to facilitate
communication or as required bye inter-agency data sharing
requirements. Applicant must enter a
valid tax identification number (TIN).
Debt collection
information is mandatory pursuant to the Debt Collection
Improvement Act of 1996.
SECTION
2.
BUSINESS ACTIVITY -
Indicate only one.
SECTION
3.
DRUG SCHEDULES -
Applicant should check all drug schedules to be handled.
However, applicant must still comply with state requirements;
federal registration does not overrule state restrictions. Check
the order form box only if you intend to purchase or to transfer
schedule II controlled substances. Order forms will be mailed to
the registered address following issuance of a Certificate of
Registration.
SECTION
4.
STATE LICENSE(S) -
Federal registration by DEA is based upon the applicant's
compliance with applicable state and local laws. Applicant
should contact the local state licensing authority prior to
completing this application.
SECTION
5.
LIABILITY -
Applicant must answer all four questions for the application to
be accepted for processing. If you answered "Yes" to
any question, provide an explanation in the space provided. If
you answer "Yes" to several of the questions, then you
must provide a separate explanation describing the location,
nature and result of incident for each "Yes" answer. If
additional space is required, you may attach a separate sheet of
paper.
SECTION
6.
EXEMPTION FROM APPLICATION FEE - Exemption from payment of application fee is
limited to federal, state or local government official or
institution. The applicant's superior or agency officer
must certify exempt status. The signature, authority title, and
telephone number of the certifying official (other than the
applicant) must be provided. The address of the fee exempt
institution must appear in Section 1.
SECTION
7.
METHOD OF PAYMENT -
Indicate the desired method of payment. Make checks payable to
"Drug Enforcement Administration". Third-party checks
or checks drawn on foreign banks will not be accepted.
FEES ARE
NON-REFUNDABLE.
SECTION
8.
APPLICANT'S SIGNATURE
- Applicant MUST sign in this section or application will be
returned. Card holder signature in section 7 does not fulfill
this requirement.
Notice
to Registrants Making Payment by Check
Authorization to Convert
Your Check:
If you send us a check to
make your payment, your check will be converted into an electronic
fund transfer. "Electronic fund transfer" is the term
used to refer to the process in which we electronically instruct
your financial institution to transfer funds from your account to
our account, rather than processing your check. By sending your
completed, signed check to us, you authorize us to copy your check
and to use the account information from your check to make an
electronic fund transfer from your account for the same amount as
the check. If the electronic fund transfer cannot be processed for
technical reasons, you authorize us to process the copy of your
check.
Insufficient Funds:
The electronic funds
transfer from your account will usually occur with 24 hours, which
is faster than a check is normally processed. Therefore, make sure
there are sufficient funds available in your checking account when
you send us your check. If the electronic funds transfer cannot be
completed because of insufficient funds, we may try to make the
transfer up to two times.
Transaction
Information:
The electronic fund transfer
from your account will be on the account statement you receive
from your financial institution. However, the transfer may be in a
different place on your statement than the place where your checks
normally appear. For example, it may appear under "other
withdrawals" or "other transactions." You will not
receive your original check back from your financial institution.
For security reasons, we will destroy your original check, but we
will keep a copy of the check for record-keeping purposes.
Your Rights:
You should contact your
financial institution immediately if you believe that the
electronic fund transfer reported on your account statement was
not properly authorized or is otherwise incorrect. Consumers have
protections under Federal law called the Electronic Fund Transfer
Act for an unauthorized or incorrect electronic fund transfer.
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