Dea Form 254 – Fill Out and Use This PDF

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	Information Description
Applicant Last Name	Enter the last name of the applicant.
Applicant First Name	Enter the first name of the applicant.
MI	Enter the middle initial of the applicant. Enter ‘X’ if the applicant
	does not have a middle initial.
Applicant Social	Enter the Social Security Number of the applicant. This information
Security Number	will be kept private and used for internal purposes as stated in the
	Privacy Policy.
Addendum _ of _	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: CSOSsupport@deaecom.gov

Instructions for completing DEA Form 254

CSOS Certificate Application Registrant List Addendum

Section 2 – DEA Registration List

Field Name	Information Description
DEA Registration	Enter the DEA Registration Number(s) for which the applicant will
Num	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.
DEA Registration	Enter the name of the DEA Registered location(s) as it appears on
Name	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	Information Description
Applicant	The applicant must sign and date the application using blue or black
Signature, Date	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).
Notary Signature,	Registrant and Coordinator Applicants - A CERTIFIED
Date	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 0.72 hour, 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: CSOSsupport@deaecom.gov

Form DEA-254 (01/2010)	Approved OMB
	1117-0038
	NO.

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.