The ORIGINAL is submitted to DEA for processing.
The duplicate is retained in the importer's files
until the shipment is received. At that time, the following information
should be entered in Item 6c: DEA import permit number, actual quantity
imported and date received. After this information is entered, it is
requested that a copy be made and forwarded to DEA.
| Item A |
- |
Enter date application prepared. |
| Item B |
- |
Enter the application number. The number is
solely for the use of the importer. |
| Item C/D |
- |
Enter name/address of importer as shown
on DEA registration certificate. Address must be that to which the substance will be
shipped.
Permits will be mailed to the importer at this
address unless contrary instructions are attached to and made part of
this application. |
| Item E |
- |
Enter importer's telephone number (telephone
number for the person whoactually completes the form in case there are any
questions). |
| Item F |
- |
Enter importer's DEA registration number. |
| Item G |
- |
Enter signature and title of the person
making application. |
|
| Item 1/2 |
- |
Enter the name and address of the foreign
exporter.
Note that controlled substances may not be imported by
mail or parcel post! |
| Item 3 |
- |
Enter city and country of foreign port of
exportation. |
| Item 4 |
- |
Enter city and state of domestic port of
importation (U.S. Customs port where substance will be cleared). |
| Item 5 |
- |
Enter latest date shipment will leave foreign
port of exportation. |
| Item 6a |
- |
Enter names as shown on labels; numbers
and sizes of packages; strength of tablets, capsules, etc.; CSA Drug
Code, and NDC Number (if known). |
| Item 6b |
- |
Enter name and controlled substance
content (in grams) of drug, compound or preparation to be imported, as
well as the anhydrous acid, base or alkaloid content (in grams), if
applicable. |
| Item 6c |
- |
Enter the DEA import permit number, date
received and actual quantity imported once the shipment has been
received and forward a copy to DEA. |
| Item 7a-7d |
- |
Only importers of crude opium, poppy
straw, concentrate of poppy straw, and coca leaves complete this item. |
| Item 8 |
- |
If applicable, enter brief statement as
to scientific uses for which the substance will be put after its
importation, e.g., "For chemical and clinical study of its
properties and suitability for medical distribution." Also, enter
signature of certifying individual. |
