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 1; 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, point of contact, national provider id, and date of birth are new data items that are in the process of OMB approval and will soon be mandatory. They are requested in order to facilitate communication o0r as required by inter-agency sharing requirements. Applicants must enter a valid social security number (SSN), or a tax identification number (TIN) if applying as a business entity.

Debt collection information is mandatory pursuant to the Debt Collection Improvement Act of 1996.

SECTION 2. BUSINESS ACTIVITY 

Indicate only one. Each type of business activity requires a separate application. You are required to register as a "manufacturer" if you manufacture a controlled substance or list 1 chemical and then distribute it.

SECTION 3A. DRUG SCHEDULES 

Applicants should check all drug schedules to be handled. However, applicants 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 1 and 2 controlled substances. Order forms will be mailed to the registered address following issuance of a Certificate of Registration.

3B. MANUFACTURERS ONLY 

Mark the controlled substance schedule(s) handled in each manufacturing stage listed.

3C. SCHEDULE CODES 

Report all drug codes as required for your business activity. Analytical labs are not required to list drug codes. Researchers of schedule 2-5 need only report schedule 2 drug codes that will be manufactured or imported as part of the research activity. Researchers of schedule 1 must report drug codes. Distributors or reverse distributors must list all schedule 1 and/or 2012 codes.  Importers and Exporters must check all schedule codes handled. Manufacturer must report all schedule 1 and 2 drug codes, and check all codes that are manufactured in bulk.

SECTION 4. STATE LICENSE(S) 

Federal registration by DEA is based upon the applicant 's compliance with applicable state and local laws. Applicants should contact the local state licensing authority prior to completing this application. If your state requires a license, provide that number on this application. 

SECTION 5. LIABILITY 

Applicants 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 answered "Yes" to several of the question, 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 

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 

Applicants MUST sign in this section or the application will be returned. Card holder signature in section 7 does not fulfill this requirement.

ATTACHMENTS:

Researchers must attach 3 copies of protocol, including curriculum vitae, to conduct research with schedule I controlled substances. For clinical investigations, researchers must first submit to FDA a "Notice of Claimed Investigational Exemption for New Drug (IND)". See DEA web site or CFR 1301.18 for further details.

NOTICE TO REGISTRANTS PAYING BY CHECK

Authorization to Convert Your Check:

Checks will be converted via electronic fund transfer (EFT). EFT is the term used to refer to the process where we electronically instruct your financial institution to transfer funds from your account to our account, rather than processing your check. By sending a completed, signed check, you authorize us to copy your check and to use the account information from your check to make an EFT from your account for the same amount on the check. If the EFT cannot be completed for technical reasons, you authorize us to process the copy of your check.

Insufficient Funds:

The EFT from your account will usually occur within 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 EFT cannot be completed because of insufficient funds, we may try to make the transfer up to two times.

Transaction Information:

The EFT 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 scanned copy of the check for record-keeping purposes.

Your Rights:

You should contact your financial institution immediately if you believe that the EFT 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.