DEA-252 CSOS Principal Coordinator/Alternate Coordinator Certifi

Instructions for completing DEA Form 252
New CSOS Principal Coordinator/Alternate Coordinator Certificate
Application
This application is for individuals applying to fulfill the role of CSOS Principal
Coordinator or Alternate Coordinator. A Principal Coordinator shall be identified for
each DEA Registration participating in the Controlled Substance Ordering System. The
Principal Coordinator shall serve as an organization’s primary CSOS correspondence
with regards to CSOS Certificate applications, renewals, and revocations for the DEA
Registration(s) identified on their application. The Principal Coordinator applicant may
be any individual employed by the organization. Submission of this application is not
required if the DEA Registrant will serve the role of Principal Coordinator and has so
indicated on his/her New CSOS DEA Registrant Certificate Application.
Optionally an organization may identify an Alternate Coordinator. Individuals acting as
Alternate Coordinator shall serve as an organization’s CSOS contact in the absence of the
Principal Coordinator for the DEA Registration(s) identified on their application.
Alternate Coordinator applicants may be any individuals employed by the organization.
Principal Coordinator / Alternate Coordinator applicants will receive either a CSOS
Administrative Certificate or a CSOS Power of Attorney Certificate dependant upon the
applicant’s response to the questions posed in Section – 2 Applicant Classification.
An approved Principal Coordinator/Alternate Coordinator shall serve as the primary
Local Registration Authority (LRA) for the DEA Registration(s) identified on their
application. Serving in the role of LRA the Principal Coordinator/Alternate Coordinator
shall be responsible for verifying the identity and applicability of organization personnel
applying for a CSOS Certificate.
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 required fields must be completed.
Section 1 – Applicant Information
Field Name

Applicant Last
Name
Applicant First
Name
Applicant MI
Applicant Social
Security Number

Required
or
Optional

Information Description

Required

Enter the last name of the applicant.

Required

Enter the first name of the applicant.

Required
Required

Enter the middle initial of the applicant.
Enter the Social Security Number of the applicant.
This information will be kept private and used for
internal purposes as stated in privacy policy.

Field Name

Required
or
Optional

Applicant Business Required
Phone Number

Applicant E-Mail
Address

Required

Applicant
Mother’s Maiden
Name
DEA Registration
Num

Required

DEA Registration
Name

Required

Required

Applicant Business Required
Address

Information Description

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.
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
Enter mother’s maiden name of the applicant. This
information will be kept private and used for security
purposes.
Enter the DEA Registration Number for which the
applicant will be responsible. 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.
Enter the business address of the CSOS Coordinator
applicant. This address may be used for
correspondence concerning your CSOS application
and/or CSOS certificate applications, renewals and
revocations.

Section 2 – Applicant Classification
Field Name

Are you applying
as Principle
Coordinator
Alternate
Coordinator

Required
or
Optional

Required

Information Description

Check the appropriate box.

Field Name

Do you also wish
to obtain a CSOS
POA Certificate
for signing
controlled
substance orders
for the identified
DEA
Registration(s)?

Required
or
Optional

Required

Information Description

Check the Yes box if the applicant would like to
obtain a CSOS Power of Attorney Certificate for
signing controlled substance orders for the identified
DEA Registration.
Check the NO box if the applicant is not interested in
obtaining a CSOS Power of Attorney Certificate.

Section 3 – Applicant/Notary Signature
Field Name

Required
or
Optional

Applicant
Signature

Required

Notary Signature

Required

Information Description

The applicant must sign the application using blue or
black ink. This signature must be applied IN THE
PRESENCE of a certified notary public. The party
signing this application must be the same party listed
in section 1 – Applicant Information (First Name /Last
Name/MI).
A CERTIFIED NOTARY PUBLIC must sign using
blue or black ink and seal/stamp each page of the
application.

Section 4 – DEA Registrant’s Affirmation of Delegation of Coordinator
Field Name

Required
or
Optional

Organization
Name

Required

Organization
Address

Required

Signature of DEA
Registrant

Required

Information Description

The organization name under which the DEA
registration(s) listed is registered as it is registered
with state business licensing
The organization address under which the DEA
registration(s) listed is registered as it is registered
with state business licensing.
Signature of the DEA Registrant. The 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. By signing this block, the DEA
Registrant certifies that the applicant identified in
Section 1 has been delegated to act as CSOS

Last Name
First Name

Required
Required

Coordinator for the above organization and identified
DEA Registration(s).
Printed last name of the DEA Registrant.
Printed first name of the DEA Registrant.

Section 5 – Applicant Signature
Field Name
Applicant
Signature

Required
or
Optional

Required

Information Description

The applicant must sign the application using blue or
black ink. This signature must be applied IN THE
PRESENCE of a certified notary public. The party
signing this application must be the same party listed
in section 1 – Applicant Information (First Name /Last
Name/MI).

Section 6 – Notary Acknowledgement
Field Name
Notary
Acknowledgement

Required
or
Optional

Required

Information Description

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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Form DEA-252 (mm/yy)

CSOS Principal Coordinator/Alternate Coordinator Certificate Application
This application is for individuals applying to serve the role of CSOS Principal Coordinator or CSOS Alternate Coordinator. Applicants who hold a
valid Power of Attorney (POA) to obtain and sign Schedules I and/or II controlled substance orders for the DEA Registrant(s) identified will receive
a CSOS POA Certificate. 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

Section 2 – Applicant Classification
1.

Are you applying as Principle Coordinator

2.

Do you also wish to obtain a CSOS POA Certificate for signing controlled substance orders for the identified DEA Registrant(s)?
Yes

Alternate Coordinator

No

Section 3 – Applicant/Notary Signature
Applicant Signature______________________________________________________________________ Date____________
Notary Signature_________________________________________________________________________Date____________

Section 4 – DEA Registrant’s Affirmation of Delegation of Coordinator
Organization Name

Organization Address

City

State

Zip

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 for the DEA Registration numbers submitted with this application I certify the applicant listed in Section 1 has been delegated to act as CSOS
Coordinator for the above organization and identified DEA Registrant(s).

Signature of DEA Registrant ________________________________________________________________Date ___________
Last Name (Print)

First Name (Print)

Section 4 – Applicant Signature
Section 5 – 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 the 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 6 – 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