Form Dea 510 – Fill Out and Use This PDF

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YES NO

3. Has the applicant ever surrendered (for cause) or had a state professional license or 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 listed chemical(s) under state or federal law, or ever surrendered, for cause, or had a federal listed chemical/controlled registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance 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.

Printed Name of Card Holder

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 CODESzyxw Listed below are List 1 chemical codes. Check all chemical codes you handle, and mark if it is bulk or dosage form.

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

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

If you manufacture the dosage form of a chemical, check the "DOSAGE?" column after the applicable code.

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Debt collection information is mandatory pursuant to the Debt Collection Improvement Act of 1996.

SECTION 2. BUSINESS ACTIVITY - Indicate only one. Indicate only one business activity on this application. Each type of business activity requires a separate application. If you are registered with DEA to manufacture, import, export, or distribute/dispense controlled substances, you do not have to register for the same activities with drug products that contain List 1 chemicals.

ｸYou are required to register as a "manufacturer" if you manufacture a List 1 chemical and then distribute it. You do not have to register if you manufacture a List 1 chemical for internal consumption with no subsequent distribution of it.

ｸRegistration as an importer conveys distribution privileges only for those List 1 chemicals imported.

SECTION 3. DRUG SCHEDULES - Applicants is registering for l List 1 chemicals on this application. However, applicants must still comply with state requirements; federal registration does not overrule state restrictions.

3B. MANUFACTURER ONLY - Mark the appropriate box to indicate if you are manufacturing List 1 chemicals in bulk or dosage form.

3C. CHEMICAL CODES - Applicant must check all List 1 chemicals to be handled and indicate if the chemical is in bulk or dosage form.

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 information and attach a copy to this application. If YOUR STATE DOES NOT REQUIRE A LICENSE, MARK AN "X" IN THE BOX TO INDICATE IT NOT REQUIRED BY YOUR STATE.

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 of the 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 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 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.

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 1117-0031. 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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