DEA-254 CSOS Certificate Application Registrant List Addendum

Instructions for completing DEA Form 254
CSOS Certificate Application Registrant List Addendum
The CSOS Certificate Application Registrant List Addendum is an addendum used for
individuals who wish to apply for a CSOS Certificate for more than one DEA Registrant. Up to
five (5) Registrant List Addendums may be submitted with any of the CSOS Certificate
applications; the CSOS DEA Registrant Certificate Application, the CSOS Principal Coordinator
/ Alternate Coordinator Application or the CSOS POA Certificate Application.
Applicants who wish to apply for more than 50 CSOS Certificates with one CSOS Certificate
Application should contact the CSOS RA for bulk enrollment procedures.
The information must be TYPED with the exception of signatures and the affirmations sections,
which must be completed in blue or black ink.
Section 1 – Applicant Information
Field Name

Applicant Last
Name
Applicant First
Name
Applicant MI
Applicant Social
Security Number
Addendum _ of _
DEA Reg.
Prin. Coord.
Alt. Coord.
POA

Information Description

Enter the last name of the applicant.
Enter the first name of the applicant.
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.
Enter the page number of the addendum and the total number of
addendums attached. Example 1 of 3, 2 of 3, 3 of 3.
Check this box if you are applying as a DEA Registrant for the DEA
Registration numbers identified in Section 2. This box may not be
checked if the POA box is checked.
Check this box if you are applying as a Principal Coordinator for the DEA
Registration numbers identified in Section 2. This box may not be
checked if the Alt. Coord. Box is checked.
Check this box if you are applying as a Alternate Coordinator for the
DEA Registration numbers identified in Section 2. This box may not be
checked if the Prin. Coord. box is checked.
Check this box if you are applying to receive a Power of Attorney
Certificate for the DEA Registration numbers identified in Section 2. This
box may not be checked if the DEA Reg. box is checked.

Section 2 – DEA Registration List
Field Name

DEA Registration
Num

DEA Registration
Name

Information Description

Enter the DEA Registration Number(s) for which the applicant will be
responsible. The number(s) 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(s) as it appears on the
DEA 223 Certificate. Inconsistency between the application and the
registration certificate will result in approval delays or denial.

Section 3 – Applicant/Notary Signature
Field Name

Applicant
Signature

Notary Signature

Information Description

The applicant must sign the application using blue or black ink. The party
signing this application must be the same party identified in Section 1 –
Applicant Information (First Name /Last Name/MI).
DEA Registrant and CSOS Coordinator applicants are required to apply
their signature IN THE PRESENCE of a certified notary public. It is the
responsibility of the applicant to ensure that all information is completed.
DEA Registrant & CSOS Coordinator applicants - A Certified Notary
Public must sign the Registration List Addendum(s) attached to the
Certificate application using blue or black ink.
Power of Attorney applicants - The CSOS Coordinator must sign the
Registration List Addendum(s) attached to the Certificate application
using blue or black ink.

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.

Form DEA-254

Approved OMB
NO.1117-00##

(11-00)

CSOS Certificate Application Registrant List Addendum
CSOS Certificate applicants shall complete this addendum to identify additional DEA Registrants for which a CSOS Certificate shall be issued. A CSOS
Certificate application must accompany this addendum.

Section 1 – Applicant Information
Applicant Last Name

Applicant First Name

MI

Applicant SSN Number

Addendum

Of

Section 2 – DEA Registrant list
DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

DEA Registration No.

DEA Registrant Name

Section 3 –– Applicant/Notary Signature
Applicant Signature ___________________________________________________________ Date __________
Notary/CSOS Coordinator Signature _______________________________________________ Date __________