Form 225 – Fill Out and Use This PDF

Name 1 (Last Name of individual -OR- Business or Facility Name)

Name 2 (First Name and Middle Name of individual - OR- Continuation of business name)

PLACE OF BUSINESS Street Address Line 1

PLACE OF BUSINESS Address Line 2

City

State

Zip Code

Business Phone Number

Point of Contact

Business Fax Number

Email Address

Date(s) of incident MM-DD-YYYY:

YES NO

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?

Date(s) of incident MM-DD-YYYY:											Note: If question 4 does not apply to you, be sure to mark 'NO'.
											It will slow down processing of your application if you leave it blank.

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

Signature of certifying official (other than applicant)

Date

Provide the name and

phone number of the

Print or type name and title of certifying official

Telephone No. (required for verification)

certifying official

SECTION 7

Check

Make check payable to: Drug Enforcement Administration

See page 4 of instructions for important information.

METHOD OF

Mail this form with payment to:

PAYMENT

American Express

Discover

Master Card

Visa

Check one form of

Credit Card Number

Expiration Date

DEA Headquarters

payment only

ATTN: Registration Section/ODR

P.O. Box 2639

Springfield, VA 22152-2639

Sign if paying by

Signature of Card Holder

FEE IS NON-REFUNDABLE

credit card

Printed Name of Card Holder

SECTION 8

I certify that the foregoing information furnished on this application is true and correct.

APPLICANT'S

SIGNATURE

Signature of applicant

(sign in ink)

Date

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.

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C. SCHEDULE AND DRUG CODES

Listed below are examples of schedules 1-5 and List 1 codes. Check all drug codes you handle as required.

For more information, see our website at www.deadiversion.usdoj.gov, 21 CFR 1308, or call 1-800-882-9539.

Canine Handler	must mark schedule 1	Distributor	must mark all schedule 1, drug code 2012
Exporter	must mark all schedule 1-5	Reverse Distributor	must mark all schedule 1, drug code 2012
Importer	must mark all schedule 1-5 & List 1 codes	Researcher w/Sched 1	must mark schedule 1
Manufacturer	must mark all schedule 1, 2 & List 1 codes	Researcher w/Sched 2-5	must mark schedule 2 to be manufactured or imported
			as part of research

If you bulk manufacture a substance, check the 'BULK?' column after the applicable class code.

SCHEDULE 1 NARCOTIC & NON-NARCOTIC			CODE	BULK?		SCHEDULE 2 NARCOTIC & NON-NARCOTIC		CODE	BULK?
	3,4-Methylenedioxyamphetamine (MDA)		7400				Amobarbital (Amytal, Tuinal)	2125
	3,4-Methylenedioxymethamphetamine (MDMA)		7405				Amphetamine (Dexedrine, Adderall)	1100
	4-Methyl - 2,5 - Dimethoxyamphetamine (DOM, STP)		7395				Cocaine (Methyl benzoylecgonine)	9041
	4-Methylaminorex (cis isomer) (U4Euh, McN-422)		1590				Codeine (Morphine methyl ester)	9050
	Alphacetylmethadol (except LAAM)		9603				Dextropropoxyphene (bulk)	9273
	Bufotenine (Mappine)		7433				Diphenoxylate	9170
	Marihuana / Cannabidiol		7360				Fentanyl (Duragesic)	9801
	Diethyltryptamine (DET) (		7434				Hydrocodone (Dihydrocodeinone)	9193
	Difenoxin 1MG/25UG AtSO4 /DU (Motofen)		9167				Hydromorphone (Diaudid)	9150
	Dimethyltryptamine (DMT)		7435				Levo-Alphacetylmethadol (LAAM)	9648
	Etorphine (except HCL)		9056				Levorphanol (Levo-Dromoran)	9220
	Gamma Hydroxybutyric Acid (GHB)		2010				Meperidine (Demerol, Mepergan)	9230
	Heroin (Diamorphine)		9200				Methadone (Dolophine, Methadose)	9250
	Ibogaine		7260				Methamphetamine (Desoxyn)	1105
	Lysergic acid diethylamide (LSD)		7315				Methylphenidate (Concerta, Ritalin)	1724
	Mescaline		7381				Morphine (MS Contin, Roxanol)	9300
	Marihuana		7360				Opium, powdered	9639
	Methaqualone (Quaalude)		2565				Oxycodone (Oxycontin, Percocet)	9143
	Normorphine		9313				Oxymorphone (Numorphan)	9652
	Peyote		7415				Pentobarbital (bulk) (Nembutal)	2270
	Psilocybin		7437				Phencyclidine (PCP)	7471
	Tetrahydrocannabinols (THC)		7370				Secobarbital (Seconal, Tuinal)	2315
SCHEDULE 3 NARCOTIC & NON-NARCOTIC			CODE	BULK?		SCHEDULE 4 NARCOTIC & NON-NARCOTIC		CODE	BULK?
	Anabolic Steroids		4000				Alprazolam (Xanax	2882
	Barbituric acid derivative		2100				Barbital (Veronal, Plexonal)	2145
	Benzphetamine (Didrex, Inapetyl)		1228				Chloral Hydrate (Noctec)	2465
	Buprenorphine (Buprenex, Temgesic)		9064				Chlordiazepoxide (Librium)	2744
	Butabarbital		2100				Clonazepam (Klonopin)	2737
	Butalbital		2100				Clorazepate (Tranxene)	2768
	Codeine combo product (Empirin)		9804				Diazepam (Valium)	2765
	Dihydrocodeine combo product (Compal)		9807				Flurazepam (Dalmane)	2767
	Dronabinol in sesame oil soft cap (Marinol)		7369				Lorazepam (Ativan)	2885
	Gamma-Hydroxybutyric Acid preparations (Zyrem)		2012				Meprobamate (Milltown, Equanil)	2820
	Hydrocodone combo products (Lorcet, Vicodin)		9806				Midazolam (Versed)	2884
	Ketamine (Ketaset, Ketalar)		7285				Oxazepam (Serax, Serenid-D)	2835
	Morphine combo product		9810				Phenobarbital (Fastin, Zantryl)	2285
	Nalorphine (Nalline)		9400				Phentermine	1640
	Opium combo product (Paregoric)		9809				Temazepam (Restoril)	2925
	Pentobarbital suppository dosage (FP3)		2270				Zolpidem (Ambien, Stilnox)	2783
	Phendimetrazine (Plegine, Bontril)		1615			LIST 1 REGULATED CHEMICALS		CODE	BULK?
	Thiopental		2100			** ONLY manufacturers & importers may select List 1
SCHEDULE 5 NARCOTIC & NON-NARCOTIC			CODE	BULK?			Ephedrine	8113
	Codeine preparations (Robitussin A-C, Pediacof)		9050				Phenylpropanolamine	1225
	Pyrovalerone (Centroton, Thymergix)		1485				Pseudoephedrine	8112
WRITE IN ADDITIONAL CODES		You may write in additional drug codes in this section. Attach a separate sheet if needed.

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Form-225

APPLICATION FOR REGISTRATION

Supplementary Instructions and Information

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. 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.

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. SCHEDULES - Applicant should check all 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 1 and 2 controlled substances. Order forms will be mailed to the registered address following issuance of a Certificate of Registration.

3B. MANUFACTURER ONLY - Mark the chemical/controlled substance schedule(s) handled in each manufacturing stage listed.

3C. SCHEDULE CODES - Report all chemical/drug codes as required for your business activity. Controlled substances manufacturers and importers must obtain a separate chemical registration if they handle chemicals other than an FDA-approved drug product containing 1225, 8112, or 8113.

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. If your state requires a license, provide that number on this application.

SECTION 5. LIABILITY - Applicant 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 questions, then you must provide a separate explanation describing the date, location, nature, and result of each incident. If additional space is required, you may attach a separate page.

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 - 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.

ATTACHMENTS: Researcher or canine handler must attach 3 copies of protocol, including curriculum vitae, to conduct research with schedule 1 controlled substances. For clinical investigations, researcher must first submit to FDA a "Notice of Claimed Investigational Exemption for New Drug (IND)". See DEA web site or CFR 1301.18 for details.

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 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 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 form 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 1117-0012. 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 Act 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, State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes, and person 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 System of Records Notice "Controlled Substances Act Registration Records" (DEA-005), 52 FR 47208, December 11, 1987, as modified.

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