Form DEA-251 CSOS DEA Registrant Certificate Application

Instructions for completing DEA Form 251
CSOS DEA Registrant Certificate Application
This application is for DEA Registrants who wish to receive a CSOS Certificate. A DEA
Registrant is defined as the individual who signed the most recent application for DEA
Registration or the individual authorized to sign the most recent application for DEA
Registration. Only DEA Registrants may submit a CSOS DEA Registrant Certificate
Application. DEA Registrant applicants will receive a CSOS DEA Registrant Certificate for the
DEA Registration(s) identified and will fulfill the role of Principal Coordinator unless otherwise
indicated in the Coordinator Name field of Section 1 – Applicant Information.
The applicant should review the CSOS DEA Registrant Application Checklist to ensure all
required documents are included with their application prior to mailing the application package
to the CSOS Registration Authority.
Mail the completed application and attachments to:
Drug Enforcement Administration
Office of Diversion Control
E-Commerce Program
Attention: CSOS Certificate Enrollment
Washington D.C. 20537
The information must be TYPED with the exception of signatures and the affirmations and the
notary acknowledgement sections, which must be completed in blue or black ink. All fields must
be completed.
Section 1 – Applicant Information
Field Name

Information Description

Applicant Last
Name

Enter the last name of the applicant.

Applicant First
Name

Enter the first name of the applicant.

Applicant MI

Enter the middle initial of the applicant.

Applicant Social
Security Number
Applicant Business
Phone Number

Enter the Social Security Number of the applicant. This information will
be kept private and used for internal purposes as stated in privacy policy.
Enter the business phone number for the applicant. This phone number
will be kept private and will be used only when necessary for
correspondence concerning your CSOS application or CSOS digital
certificate.

Section 1 – Applicant Information (Cont.)
Field Name

Information Description

Applicant E-Mail
Address

Enter the business email address for the applicant. This email address
will be kept private and will be used for correspondence concerning your
CSOS application or CSOS

Applicant
Mother’s Maiden
Name

Enter mother’s maiden name of the applicant. This information will be
kept private and used for security purposes.

DEA Registration
Num

Enter the DEA Registration Number for which a the applicant shall serve
the role of Principal Coordinator and/or a CSOS Certificate shall be
issued. If The number entered on the application MUST appear as it does
on the registrant’s DEA Registration Certificate. Inconsistency between
the application and the registration certificate will result in approval
delays or denial.
Enter the name of the DEA Registered location as it appears on the DEA
223 Certificate. Inconsistency between the application and the registration
certificate will result in approval delays or denial.

DEA Registration
Name

Applicant Business Enter the business address of the CSOS Coordinator applicant. This
Address
address may be used for correspondence concerning your CSOS
application and/or CSOS certificate applications, renewals and
revocations.
CSOS Coordinator Enter the last name of the individual who will fulfill the role of Principal
Last Name
Coordinator for the DEA Registration number(s) identified. This should
be the applicant’s name if applicant will fulfill the role of Principal
Coordinator.
CSOS Coordinator Enter the first name of the individual who will fulfill the role of Principal
First Name
Coordinator for the DEA Registration number(s) identified. This should
be the applicant’s name if applicant will fulfill the role of Principal
Coordinator.
Section 2 – Applicant Signature
Field Name

Applicant
Signature

Information Description

The applicant must sign the application using blue or black ink. The party
signing this application must be the same party listed in section 1 –
Applicant Information (First Name /Last Name/MI).

Section 3 – Notary Acknowledgement
Field Name

Information Description

Notary
Acknowledgement

A CERTIFIED NOTARY PUBLIC must complete the Acknowledgement
section using blue or black ink. All fields in this section, including the
notary seal/stamp must be completed. The Applicant must sign the
application in the presences of the CERTIFIED NOTARY PUBLIC. It is
the responsibility of the applicant to ensure that all information is
completed.

Warning: When the applicant signs the application, he/she is stating that he/she has read,
understands, and agrees to abide by the rules and regulations contained in the Controlled
Substance Ordering System Subscriber Agreement and Certificate. 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.

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CSOS DEA Registrant Certificate Application

This application must be completed by the individual who signed the most recent application for DEA Registration (DEA Registrant) or the
individual authorized to sign the most recent DEA Registration application. Read instructions before completing.

Section 1 – Applicant Information
Applicant Last Name

Applicant First Name

MI

Applicant SSN Number

Applicant Bus. Phone

Applicant E-Mail Address

DEA Registration No.

DEA Registrant Name

Security Code (e.g. Mother’s Maiden Name) Letters only. Remember this code to ensure proper identification when you call

No. of Addendums

Applicant Business Address

City

State

Zip

CSOS Coordinator Last Name (If not applicant then form # must be submitted by individual named below)

CSOS Coordinator First Name (If not applicant then form # must be submitted by individual named below)

Section 2 – Applicant Signature
By signing this document, I am stating that I have read, understand and agree to abide by the rules and regulations contained in the Controlled Substance Ordering
System Subscriber Agreement and DEA CSOS Registrant Agreement. I am also certifying that the information, statements, and representations provided by me on
this form are true and accurate to the best of my knowledge. I understand 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.

Applicant Signature ______________________________________________________________________ Date ___________
Section 3 –– Notary Acknowledgement
Instructions to Notary: 1. Modify this form where necessary to assure compliance with the laws of your jurisdiction. Use the back of
the form if necessary. 2. Notary must fully complete the Acknowledgement below 3. Sign and seal/stamp both pages of the form. 4.
Identification #1 must be a government-issued, widely recognized form of photo ID, such as Driver's License or Passport. ID #2 does not
require a photo, but must be different form of ID. Examples: Valid government issued ID, employee ID card, utility or tax bill, major
insurance card, and no more then one national credit card
State or Commonwealth of ______________________ County of______________________ Country_______________
On______________________ before me,_________________________ personally appeared
________________________________(Applicant) proved to me on the basis of the presentation of two forms of identification listed below
to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same, and that by
his/her signature on the instrument the person executed the instrument in my presence.
ID #1 (with photograph)
ID #2 (with photograph)

Type:____________ Identifying Number:________________ Expiration Date:__________
Type:____________ Identifying Number:________________ Expiration Date:__________

Witness my hand and official seal.
Notary's Signature:_____________________________________________________________________________
Notary's Name (Print or Type):___________________________________________________________________
Notary's Address:_______________________________________________________
Notary's Phone:_______________________ My Commission Expires:_____________

Notary Stamp/Seal