DEA-253 CSOS Power Of Attorney Certificate Application

Instructions for completing DEA Form 253
New CSOS Power of Attorney Certificate Application
This application is for Powers of Attorney (POA) of DEA Registrants who wish to obtain
a CSOS POA Certificate. The POA applicant must have been granted Power of Attorney
to sign controlled substance orders for the DEA Registration(s) identified. The Principal
Coordinator/Alternate Coordinator must verify the identity and applicability of the POA
applicant in accordance with the DEA CSOS Registrant Agreement.
The information must be TYPED with the exception of the signature and the affirmation
sections, which must be completed in blue or black ink. All required fields must be
completed.
Section 1 – Applicant Information
Field Name

Required
or
Optional

Information Description

Applicant Last
Name

Required

Enter the last name of the applicant.

Applicant First
Name

Required

Enter the first name of the applicant.

Applicant MI

Required

Enter the middle initial of the applicant.

Applicant Social
Security Number

Required

Applicant
Business Phone
Number

Required

Applicant E-Mail
Address

Required

Applicant
Mother’s Maiden
Name

Required

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.
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.

DEA
Required
Registration Num

Enter the DEA Registration Number for which a CSOS
Certificate shall be issued. 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.

Field Name

DEA
Registration
Name

Required
or
Optional

Required

Information Description

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.

Section 2 – Applicant Signature
Field Name

Applicant
Signature

Required
or
Optional

Required

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 – DEA Registrant/CSOS Coordinator Affirmation of Applicant Identity
Verification
Field Name

Required
or
Optional

DEA
Registrant/CSOS
Coordinator
Signature

Required

Last Name
(Print)
First Name
(Print)

Required
Required

Information Description

Signature of Principal Coordinator or Alternate
Coordinator responsible for the DEA Registration(s)
identified, or the DEA Registrant if the registrant is
serving the role of Principal Coordinator. By signing
this block, the Principal Coordinator/Alternate
Coordinator attests to verifying the identity and
applicability of the applicant identified in Section 1 in
accordance with the DEA CSOS Registrant Agreement
Printed last name of Principal Coordinator/Alternate
Coordinator
Printed first name of Principal Coordinator/Alternate
Coordinator

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-253 (mm/yy)

CSOS Power Of Attorney Certificate Application
This application is for individuals who hold valid Power of Attorney to obtain and sign Schedules I and/or II controlled substance orders for the DEA
Registrant(s) identified. Prior to submitting this application either a CSOS DEA Registrant Certificate Application (form 251) or the CSOS Principal
Coordinator\ Alternate Coordinator Certificate Application (form 252) must have been submitted for the DEA Registrant(s) identified. 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

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. 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 – DEA Registrant/CSOS Coordinator Affirmation of Applicant Identity Verification
As DEA Registrant, CSOS Principal Coordinator, or CSOS Alternate Coordinator for the DEA Registrant(s) identified I hereby affirm that I have verified the
identity and authorization of the applicant in accordance with the DEA CSOS Registrant Agreement.

DEA Registrant/CSOS Coordinator Signature _________________________________________Date__________
Last Name (Print)

First Name (Print)