Form 224A – Fill Out and Use This PDF

FEE IS NON-REFUNDABLE

MAIL-TO ADDRESS Please print mailing address changes to the right of the address in this box.

SECTION 1 UPDATE REGISTRATION INFORMATION - Please fill in missing information and make corrections if needed to any data we have on record for your registration.

Name 1 :

Name 2 :

PLACE OF

BUSINESS

Street

Address

Line 1 :

PLACE OF

BUSINESS

Address

Line 2 :

City

State :

Zip

224A RENEWAL - Page 1

1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law,

LIABILITY or been excluded or directed to be excluded from participation in a medicare or state health care program, or is any such action pending?

4.If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association, partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?

SECTION 6 EXEMPTION FROM APPLICATION FEE

Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution, and is exempt from payment of the application fee.

FEE EXEMPT

CERTIFIER

Sign in ink

Print or type name and title of applicant

WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000, or both.

4. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association, partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?

SECTION 6 EXEMPTION FROM APPLICATION FEE

Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution, and is exempt from payment of the application fee.

FEE EXEMPT

CERTIFIER

Sign in ink

Print or type name and title of applicant

WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000, or both.

1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law,

LIABILITY or been excluded or directed to be excluded from participation in a medicare or state health care program,or is any such action pending?

4. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association, partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?

SECTION 6 EXEMPTION FROM APPLICATION FEE

Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution, and is exempt from payment of the application fee.

FEE EXEMPT

CERTIFIER

Sign in ink

Print or type name and title of applicant

WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000, or both.

NEW - Page 2

SECTION 1. UPDATE REGISTRATION INFORMATION - Each data field displays the information we have on record for your registration. Fill in blanks, update and correct data in the blocks provided. 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 federal or state fee exempt institution.

Applicant 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.

The email address, point of contact, national provider id, date of birth, year graduated, and professional school are new data items that are used to facilitate communication or as required by inter-agency data sharing requirements. They are requested in order to facilitate communication or as required by inter-agency data sharing requirements.

Practitioner must enter one degree from this list: DDS, DMD, DO, DPM, DVM, or MD.

Mid-level practitioner must enter one degree from this list: DOM, HMD, MP, ND, NP, OD, PA, or RPH.

IF ALL THE DATA IS CORRECT AND COMPLETE, THEN SKIP TO SECTION 2.

SECTION 2. DRUG SCHEDULES - Check the order form box only if you intend to purchase or transfer schedule 2 controlled substances. Order forms will be mailed to the registered address following issuance of a Certificate of Registration.

All the drug schedules you were certified for on previous registration are displayed above the dotted line. If you are registering for the same schedule(s) listed, CHECK THE "NO CHANGE" BOX AND THEN SKIP TO SECTION 3.

If you need to make a change, applicant should check all drug schedules to be handled from the list displayed below the dotted line. However, applicant must still comply with state requirements; federal registration does not overrule state restrictions.

The following list of drug codes are examples of controlled substances for narcotic and non-narcotic schedules 2, 3, 4, and 5.

Refer to the CFR for a complete list of basic classes.

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SECTION 3. 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. If your state requires a separate controlled substance number, provide that number on this application.

SECTION 4. LIABILITY - Applicants must answer all four questions for the application to be accepted for processing. If you answer "Yes" to a 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 date, location, nature, and result of each incident. If the "Yes" box is already marked, then we have that data on record from a previous registration. You must provide an explanation for the original and all subsequent [new] incidents. If additional space is required, you may attach a separate page.

SECTION 5. 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 6. 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 7. APPLICANT'S SIGNATURE - Applicant MUST sign in this section or application will be returned. Card holder signature in section 6 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 more 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.

ADDITIONAL INFORMATION

No registration will be issued unless a completed application has been received (21 CFR 1301.13).

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 number for this collection is 1117-0014. Public reporting burden for this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information.

The Debt Collection Improvements ct of 1996 (31 U.S.C. §7701) requires that you furnish your Taxpayer Identification Number (TIN) or Social Security Number (SSN) on this application. This number is required for debt collection procedures if your fee is not collectible.

PRIVACY ACT NOTICE: Providing information other than your SSN or TIN is voluntary; however, failure to furnish it will preclude processing of the application. The authorities for collection of this information are §§302 and 303 of the Controlled Substances Act (CSA) (21 U.S.C. §§822 and 823). The principle purpose for which the information will be used is to register applicants pursuant to the CSA. The information may be disclosed to other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes, tate and local law enforcement and regulatory agencies for law enforcement and regulatory purposes, and persons registered under the CSA for the purpose of verifying registration. For further guidance regarding how your information may be used or disclosed, and a complete list of the routine uses of this collection, please see the DEA ystem of Records Notice "Controlled Substances Act Registration Records" (DEA-005), 52 FR 47208, December 11, 1987, as modified.

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