Form Dea 224 PDF Details

Engaging with the complexities of handling controlled substances requires adherence to strict regulatory standards, crystallized in the DEA Form 224 application process. This critical document serves as the gateway for entities and individuals aspiring to register under the Controlled Substances Act, thereby authorizing them to prescribe, distribute, dispense, or conduct research involving controlled substances. With a meticulously outlined structure, the form necessitates comprehensive identification details from applicants, whether they are pursuing individual or business registration. Essential to the application, the specification of business activities signifies the regulatory alignment with specific controlled substance schedules, highlighting the applicant's operational scope. Furthermore, the form delves into the pivotal realm of liability, probing any historical or pending legal confrontations related to controlled substances that the applicant might have encountered. This requisite transparency extends to probing any potential revocations or suspensions of licenses or registrations, casting a wide net to ensure the integrity of applicants. Additionally, it's worth noting the fee structure, underscoring the non-refundable nature of the application fee, and delineates the payment process, accommodating various methods to ease the submission. The emphasis on accuracy and truthfulness is underscored in the certification section, reminding applicants of the grave implications of furnishing falsified information. Thus, the DEA Form 224 encapsulates a comprehensive evaluative framework, set against the backdrop of strict regulatory provisions, to vet applicants aspiring to navigate the controlled substance landscape.

QuestionAnswer
Form NameForm Dea 224
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names224 dea form, dea form 224 printable, dea form 224, dea 224

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Form-224

APPLICATION FOR REGISTRATION

 

Under the Controlled Substances Act

APPROVED OMB NO 1117-0014 FORM DEA-224 (07-11)

Previous editions are obsolete

INSTRUCTIONS

Save time - apply on-line at www.deadiversion.usdoj.gov

1.

To apply by mail complete this application. Keep a copy for your records.

 

 

2.

Mail this form to the address provided in Section 7 or use enclosed envelope.

 

3.

The "MAIL-TO ADDRESS" can be different than your "PLACE OF BUSINESS" address.

 

4.

If you have any questions call 800-882-9539 prior to submitting your application.

 

IMPORTANT: DO NOT SEND THIS APPLICATION AND APPLY ON-LINE.

 

 

MAIL-TO ADDRESS

Please print mailing address changes to the right of the address in this box.

XDEA OFFICIAL USE :

Do you have other DEA registration numbers?

NO

YES

FEE FOR THREE (3) YEARS IS $551

FEE IS NON-REFUNDABLE

SEE SECTION 1

SECTION 1 APPLICANT IDENTIFICATIION

X

Individual Registration

Business Registration

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X DEBT COLLECTION

 

Social Security Number (if registration is for individual)

 

Tax Identification Number (if registration is for business)

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mandatory pursuant

*

 

to Debt Collection

 

 

Improvements Act

 

 

X

Professional

Professional

FOR

Degree :

School :

select from

 

Practitioner

list only

 

or

National Provider Identification:

MLP

ONLY:

 

 

Provide SSN or TIN. See additional information note #3 on page 4.

Year of

Graduation :

Date of Birth (MM-DD-YYYY):

M M

D D

Y Y Y Y

X SECTION 2

Central Fill Pharmacy

BUSINESS ACTIVITY

 

Practitioner

(DDS, DMD, DO, DPM, DVM, or MD)

Ambulance Service

Check one

Retail Pharmacy

X

Practitioner Military

Animal Shelter

(DDS, DMD, DO, DPM, DVM, or MD)

business activity

 

 

 

Mid-level Practitioner (MLP)

 

box only

Nursing Home

 

Hospital/Clinic

 

(DOM, HMD, MP, ND, NP, OD, PA, or RPH)

 

 

 

 

 

 

Automated Dispensing System (ADS)

 

Euthanasia Technician

Teaching Institution

FOR Automated Dispensing System

DEA Registration #

 

 

 

An ADS is automatically fee-exempt.

 

 

 

(ADS) ONLY:

 

of Retail Pharmacy

 

 

 

Skip Section 6 and Section 7 on page 2.

 

 

 

 

You must attach a notorized affidavit.

 

 

for this ADS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X SECTION 3

Schedule 2 Narcotic

 

Schedule 3 Narcotic

Schedule 4

DRUG SCHEDULES

 

 

 

 

 

 

 

Check all that apply

Schedule 2 Non-Narcotic (2N)

 

Schedule 3 Non-Narcotic (3N)

Schedule 5

Check this box if you require official order forms - for purchase of schedule 2 controlled substances.

NEW - Page 1

XSECTION 4

STATE LICENSE

MANDATORY

You MUST be currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances in the schedules for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate.

* State License Number

*What state was this license issued in?

Expiration Date

/

/

 

 

 

 

 

 

 

 

 

MM - DD - YYYY

X SECTION 5

 

 

 

YES NO

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?

 

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

YES

NO

IMPORTANT

 

2. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended,

 

 

 

 

 

All questions in

restricted, or denied, or is any such action pending?

 

 

this section must

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

 

 

be answered.

YES

NO

 

 

 

3. Has the applicant ever surrendered (for cause) or 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:

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.

XEXPLANATION OF "YES" ANSWERS

Applicants who have answered "YES" to any of the four questions above must provide

a statement to explain each "YES" answer.

Use this space or attach a separate sheet and return with application

Liability question #

 

Location(s) of incident:

Nature of incident:

Disposition of incident:

SECTION 6 EXEMPTION FROM APPLICATION FEE

XCheck 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

PATRICIA SAUNDERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

757-953-7550

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mail this form with payment to:

METHOD OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT

American Express

 

Discover

 

Master Card

Visa

 

 

 

 

 

 

 

 

 

 

 

DEA Headquarter

Check one form of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Credit Card Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration Date

 

 

 

 

 

payment only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTN: Registration Section/ODR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P.O. Box 2639

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Springfield, VA 22152-2639

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEE IS NON-REFUNDABLE

Sign if paying by

Signature of Card Holder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

credit card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed Name of Card Holder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X 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.

NEW - Page 2

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1. It is recommended to fill out the form 224 correctly, therefore be attentive while filling out the parts including these particular blank fields:

Filling out section 1 in form dea 224 application form form

2. The subsequent step is usually to submit the next few blank fields: FOR Practitioner or MLP ONLY, SECTION BUSINESS ACTIVITY Check, National Provider Identification, Date of Birth MMDDYYYY, M M D D Y Y Y Y, Central Fill Pharmacy, Retail Pharmacy, Nursing Home, Practitioner DDS DMD DO DPM DVM or, Ambulance Service, Animal Shelter, HospitalClinic, Automated Dispensing System ADS, Euthanasia Technician, and Teaching Institution.

form dea 224 application form form writing process explained (step 2)

3. This part is going to be hassle-free - fill out all the empty fields in STATE LICENSE, MANDATORY, State License Number, What state was this license issued, SECTION, Expiration Date Has the applicant, MM DD YYYY, LIABILITY action pending, IMPORTANT, All questions in this section must, Dates of incident MMDDYYYY, Has the applicant ever, Dates of incident MMDDYYYY, Has the applicant ever, and Dates of incident MMDDYYYY in order to complete this segment.

Filling out section 3 in form dea 224 application form form

4. This fourth part arrives with the following blanks to enter your details in: Applicants who have answered YES, Nature of incident, Disposition of incident, SECTION X, EXEMPTION FROM APPLICATION FEE, Check this box if the applicant is, Does not apply to, Business or Facility Name of Fee, FEE EXEMPT CERTIFIER, Provide the name and phone number, SECTION, METHOD OF PAYMENT, Check one form of payment only, The undersigned hereby certifies, and Signature of certifying official.

Business or Facility Name of Fee, Check one form of payment only, and The undersigned hereby certifies in form dea 224 application form form

5. The document must be finalized with this particular part. Further there is a comprehensive listing of form fields that need specific details to allow your form usage to be accomplished: DEA Headquarter ATTN Registration, FEE IS NONREFUNDABLE, Sign if paying by credit card, Signature of Card Holder, Printed Name of Card Holder, SECTION, APPLICANTS SIGNATURE, Sign in ink, I certify that the foregoing, Signature of applicant sign in ink, Date, Print or type name and title of, and WARNING USC d states that any.

DEA Headquarter ATTN Registration, I certify that the foregoing, and Sign if paying by credit card inside form dea 224 application form form

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