Form 236 Controlled Substances Import/Export Declaration

U. S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117 - 0009

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION

See reverse for Privacy Act

( Read Instructions on reverse before completing)

1.

IMPORT
DECLARATION

CHECK
ONE

U.S. CUSTOMS
CERTIFICATION

Nonnarcotic Substances in Schedules III, IV, V

Date of Departure / Arrival

EXPORT
Nonnarcotic Substances in Schedules III, and IV and all substances
DECLARATION
in Schedule V
BROKER OR FORWARDING AGENT, IF USED
IMPORTER/EXPORTER (Name and Address)
(Name and Address)

Name of Carrier / Vessel
Date of Certification
Signature of Customs Official

DEA REGISTRATION NO.
2. CONTROLLED SUBSTANCES TO BE IMPORTED OR EXPORTED
2a. NAME AND QUANTITY OF DRUG or PREPARATION
(Enter names as shown on labels; numbers and sizes
of packages; strength of tablets, capsules, etc.,
CSA Drug Code and NDC Number)

3.

FOREIGN

2b. CONTROLLED SUBSTANCE CONTENT OF DRUG
OR PREPARATION expressed as acid, base or
alkaloid. (Enter names of controlled substances
contained in the drug; compound, or preparation)

DOMESTIC PORT OF EXPORTATION (last U.S.

FOREIGN

2c. DATE IMPORTED/EXPORTED
AND ACTUAL QUANTITY
(Completed by registrant at time
of transaction)

DOMESTIC PORT OF IMPORTATION (first U.S.

Customs Port) AND APPROX. DEPARTURE DATE

Customs Port) AND APPROX. ARRIVAL DATE

4.

MODE OF TRANSPORT; NAME OF VESSEL / CARRIER (if known)

NAME OF ALL INTERMEDIATE CARRIERS

5.

NAME AND ADDRESS OF FOREIGN CONSIGNEE/CONSIGNOR

Imported,
Exported, are intended for
Legitimate medical need,
Scientific research,
(If intended for reexport beyond the country of destination described in block 5 above, attach documentation per Title 21, CFR 1312.27.)

I hereby certify that the above named substance(s) to be

Other

If used as “Export Declaration”, attach documentation that importation is not contrary to the laws or regulations of the country of destination.
SIGNATURE OF AUTHORIZED INDIVIDUAL OF IMPORTER/
EXPORTER, BROKER OR FORWARDING AGENT

DEA Form
(Apr. 1988)

- 236

DATE

NAME OF FIRM AND TELEPHONE NUMBER

Previous edition dated 4/80 is OBSOLETE.

COPY 1

U. S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117 - 0009

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION

See reverse for Privacy Act

( Read Instructions on reverse before completing)

1.

IMPORT
DECLARATION

CHECK
ONE

U.S. CUSTOMS
CERTIFICATION

Nonnarcotic Substances in Schedules III, IV, V

Date of Departure / Arrival

EXPORT
Nonnarcotic Substances in Schedules III, and IV and all substances
DECLARATION
in Schedule V
BROKER OR FORWARDING AGENT, IF USED
IMPORTER/EXPORTER (Name and Address)
(Name and Address)

Name of Carrier / Vessel
Date of Certification
Signature of Customs Official

DEA REGISTRATION NO.
2. CONTROLLED SUBSTANCES TO BE IMPORTED OR EXPORTED
2a. NAME AND QUANTITY OF DRUG or PREPARATION
(Enter names as shown on labels; numbers and sizes
of packages; strength of tablets, capsules, etc.,
CSA Drug Code and NDC Number)

3.

FOREIGN

2b. CONTROLLED SUBSTANCE CONTENT OF DRUG
OR PREPARATION expressed as acid, base or
alkaloid. (Enter names of controlled substances
contained in the drug; compound, or preparation)

DOMESTIC PORT OF EXPORTATION (last U.S.

FOREIGN

2c. DATE IMPORTED/EXPORTED
AND ACTUAL QUANTITY
(Completed by registrant at time
of transaction)

DOMESTIC PORT OF IMPORTATION (first U.S.

Customs Port) AND APPROX. DEPARTURE DATE

Customs Port) AND APPROX. ARRIVAL DATE

4.

MODE OF TRANSPORT; NAME OF VESSEL / CARRIER (if known)

NAME OF ALL INTERMEDIATE CARRIERS

5.

NAME AND ADDRESS OF FOREIGN CONSIGNEE/CONSIGNOR

Imported,
Exported, are intended for
Legitimate medical need,
Scientific research,
(If intended for reexport beyond the country of destination described in block 5 above, attach documentation per Title 21, CFR 1312.27.)

I hereby certify that the above named substance(s) to be

Other

If used as “Export Declaration”, attach documentation that importation is not contrary to the laws or regulations of the country of destination.
SIGNATURE OF AUTHORIZED INDIVIDUAL OF IMPORTER/
EXPORTER, BROKER OR FORWARDING AGENT

DEA Form
(Apr. 1988)

- 236

DATE

NAME OF FIRM AND TELEPHONE NUMBER

Previous edition dated 4/80 is OBSOLETE.

COPY 2

U. S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117 - 0009

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION

See reverse for Privacy Act

( Read Instructions on reverse before completing)

1.

IMPORT
DECLARATION

CHECK
ONE

U.S. CUSTOMS
CERTIFICATION

Nonnarcotic Substances in Schedules III, IV, V

Date of Departure / Arrival

EXPORT
Nonnarcotic Substances in Schedules III, and IV and all substances
DECLARATION
in Schedule V
BROKER OR FORWARDING AGENT, IF USED
IMPORTER/EXPORTER (Name and Address)
(Name and Address)

Name of Carrier / Vessel
Date of Certification
Signature of Customs Official

DEA REGISTRATION NO.
2. CONTROLLED SUBSTANCES TO BE IMPORTED OR EXPORTED
2a. NAME AND QUANTITY OF DRUG or PREPARATION
(Enter names as shown on labels; numbers and sizes
of packages; strength of tablets, capsules, etc.,
CSA Drug Code and NDC Number)

3.

FOREIGN

2b. CONTROLLED SUBSTANCE CONTENT OF DRUG
OR PREPARATION expressed as acid, base or
alkaloid. (Enter names of controlled substances
contained in the drug; compound, or preparation)

DOMESTIC PORT OF EXPORTATION (last U.S.

FOREIGN

2c. DATE IMPORTED/EXPORTED
AND ACTUAL QUANTITY
(Completed by registrant at time
of transaction)

DOMESTIC PORT OF IMPORTATION (first U.S.

Customs Port) AND APPROX. DEPARTURE DATE

Customs Port) AND APPROX. ARRIVAL DATE

4.

MODE OF TRANSPORT; NAME OF VESSEL / CARRIER (if known)

NAME OF ALL INTERMEDIATE CARRIERS

5.

NAME AND ADDRESS OF FOREIGN CONSIGNEE/CONSIGNOR

Imported,
Exported, are intended for
Legitimate medical need,
Scientific research,
(If intended for reexport beyond the country of destination described in block 5 above, attach documentation per Title 21, CFR 1312.27.)

I hereby certify that the above named substance(s) to be

Other

If used as “Export Declaration”, attach documentation that importation is not contrary to the laws or regulations of the country of destination.
SIGNATURE OF AUTHORIZED INDIVIDUAL OF IMPORTER/
EXPORTER, BROKER OR FORWARDING AGENT

DEA Form
(Apr. 1988)

- 236

DATE

NAME OF FIRM AND TELEPHONE NUMBER

Previous edition dated 4/80 is OBSOLETE.

COPY 3

U. S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117 - 0009

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION

See reverse for Privacy Act

( Read Instructions on reverse before completing)

1.

IMPORT
DECLARATION

CHECK
ONE

U.S. CUSTOMS
CERTIFICATION

Nonnarcotic Substances in Schedules III, IV, V

Date of Departure / Arrival

EXPORT
Nonnarcotic Substances in Schedules III, and IV and all substances
DECLARATION
in Schedule V
BROKER OR FORWARDING AGENT, IF USED
IMPORTER/EXPORTER (Name and Address)
(Name and Address)

Name of Carrier / Vessel
Date of Certification
Signature of Customs Official

DEA REGISTRATION NO.
2. CONTROLLED SUBSTANCES TO BE IMPORTED OR EXPORTED
2a. NAME AND QUANTITY OF DRUG or PREPARATION
(Enter names as shown on labels; numbers and sizes
of packages; strength of tablets, capsules, etc.,
CSA Drug Code and NDC Number)

3.

FOREIGN

2b. CONTROLLED SUBSTANCE CONTENT OF DRUG
OR PREPARATION expressed as acid, base or
alkaloid. (Enter names of controlled substances
contained in the drug; compound, or preparation)

DOMESTIC PORT OF EXPORTATION (last U.S.

FOREIGN

2c. DATE IMPORTED/EXPORTED
AND ACTUAL QUANTITY
(Completed by registrant at time
of transaction)

DOMESTIC PORT OF IMPORTATION (first U.S.

Customs Port) AND APPROX. DEPARTURE DATE

Customs Port) AND APPROX. ARRIVAL DATE

4.

MODE OF TRANSPORT; NAME OF VESSEL / CARRIER (if known)

NAME OF ALL INTERMEDIATE CARRIERS

5.

NAME AND ADDRESS OF FOREIGN CONSIGNEE/CONSIGNOR

Imported,
Exported, are intended for
Legitimate medical need,
Scientific research,
(If intended for reexport beyond the country of destination described in block 5 above, attach documentation per Title 21, CFR 1312.27.)

I hereby certify that the above named substance(s) to be

Other

If used as “Export Declaration”, attach documentation that importation is not contrary to the laws or regulations of the country of destination.
SIGNATURE OF AUTHORIZED INDIVIDUAL OF IMPORTER/
EXPORTER, BROKER OR FORWARDING AGENT

DEA Form
(Apr. 1988)

- 236

DATE

NAME OF FIRM AND TELEPHONE NUMBER

Previous edition dated 4/80 is OBSOLETE.

COPY 4

U. S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117 - 0009

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION

See reverse for Privacy Act

( Read Instructions on reverse before completing)

1.

IMPORT
DECLARATION

CHECK
ONE

U.S. CUSTOMS
CERTIFICATION

Nonnarcotic Substances in Schedules III, IV, V

Date of Departure / Arrival

EXPORT
Nonnarcotic Substances in Schedules III, and IV and all substances
DECLARATION
in Schedule V
BROKER OR FORWARDING AGENT, IF USED
IMPORTER/EXPORTER (Name and Address)
(Name and Address)

Name of Carrier / Vessel
Date of Certification
Signature of Customs Official

DEA REGISTRATION NO.
2. CONTROLLED SUBSTANCES TO BE IMPORTED OR EXPORTED
2a. NAME AND QUANTITY OF DRUG or PREPARATION
(Enter names as shown on labels; numbers and sizes
of packages; strength of tablets, capsules, etc.,
CSA Drug Code and NDC Number)

3.

FOREIGN

2b. CONTROLLED SUBSTANCE CONTENT OF DRUG
OR PREPARATION expressed as acid, base or
alkaloid. (Enter names of controlled substances
contained in the drug; compound, or preparation)

DOMESTIC PORT OF EXPORTATION (last U.S.

FOREIGN

2c. DATE IMPORTED/EXPORTED
AND ACTUAL QUANTITY
(Completed by registrant at time
of transaction)

DOMESTIC PORT OF IMPORTATION (first U.S.

Customs Port) AND APPROX. DEPARTURE DATE

Customs Port) AND APPROX. ARRIVAL DATE

4.

MODE OF TRANSPORT; NAME OF VESSEL / CARRIER (if known)

NAME OF ALL INTERMEDIATE CARRIERS

5.

NAME AND ADDRESS OF FOREIGN CONSIGNEE/CONSIGNOR

Imported,
Exported, are intended for
Legitimate medical need,
Scientific research,
(If intended for reexport beyond the country of destination described in block 5 above, attach documentation per Title 21, CFR 1312.27.)

I hereby certify that the above named substance(s) to be

Other

If used as “Export Declaration”, attach documentation that importation is not contrary to the laws or regulations of the country of destination.
SIGNATURE OF AUTHORIZED INDIVIDUAL OF IMPORTER/
EXPORTER, BROKER OR FORWARDING AGENT

DEA Form
(Apr. 1988)

- 236

DATE

NAME OF FIRM AND TELEPHONE NUMBER

Previous edition dated 4/80 is OBSOLETE.

COPY 5

INSTRUCTIONS FOR COMPLETING FORM DEA-236
This form is to be used in notifying DEA of all Imports or Exports as required by Title III, PL91-513, Sections 1002 and 1003, as amended, (Controlled
Substances Import and Export Act, 21 U.S.C. 952 and 953). This form may be prepared and signed by the actual Importer or Exporter or by the Broker or
Forwarding Agent used. The following instructions supplement the parts of the DEA-236 which are not completely self-explanatory.
Part 1. “IMPORTER” means the authorized DEA registrant who receives the controlled substance; “EXPORTER” means the authorized DEA registrant
who ships the controlled substance.
Part 2. Typical entries might read:

Strength:
Size or
Weight (Bulk):
Quantity:

10 mg tablets
1,000 tablets/bottle
100 kilo/drum
100 bottles, 2 drums

If needed, use additional forms and distribute in the prescribed manner after the required documents are attached to each copy.
Part 3. Self-explanatory.
Part 4. Insert name of vessel or airline and flight number, together with all intermediate carriers. Furnish all information concerning the transportation
of the goods known at the time of preparing form DEA-236.
Part 5. Enter DEA registration number, if known, for “Import Declaration”, or foreign registration number, if applicable, for “Export Declaration”.

INSTRUCTIONS FOR DISTRUIBUTING FORM DEA-236
If this form is prepared as a Controlled Substance Import Declaration, distribute as follows:
Copies 1, 2, and 3 must be forwarded to the foreign shipper. These copies will accompany the shipment to certain points.
Upon receipt of Copies 1, 2, and 3, the foreign shipper will present Copy 1 to the proper foreign government agency or authority, if required, as a
prerequisite to export authorization. Copy 1 shall then accompany the shipment to its final destination and shall be retained in the files of the
importer for a period of at least two years.
Copy 2 shall be detached by the customs official at the foreign port.
Copy 3 shall be removed by an official of the United States Customs Service at the port of entry, certified and signed by the customs official
(after noting any discrepancies), and forwarded to the Drug Enforcement Administration, Office of Diversion Control, International Drug
Unit (ODOI), Washington, D.C. 20537.
Copy 4 must be forwarded at least 15 days prior to importation to the Drug Enforcement Administration, Office of Diversion Control, International
Drug Unit (ODOI), Washington, D.C. 20537.
Copy 5 must be retained by the importer until receipt of Copy 1.
If this form is prepared as a Controlled Substance Export Declaration, distribute as follows:
Copies 1, 2, and 3 shall accompany the shipment to certain points.
Copy 1 shall remain with the shipment to its final destination.
Copy 2 shall remain with the shipment, to be detached and retained by the customs official of the foreign port of importation.
Copy 3 shall be removed by an official of the United States Customs Service at the domestic port of exportation, certified and signed by the
customs official (after noting any discrepancies), and forwarded to the Drug Enforcement Administration, Office of Diversion Control,
International Drug Unit (ODOI), Washington, D.C. 20537.
Copy 4 shall be forwarded at least 15 days prior to exportation to the Drug Enforcement Administration, Office of Diversion Control, International
Drug Unit (ODOI), Washington, D.C. 20537. In cases where the 15 day notice cannot be given, a special waiver may be requested from the
Administration.
Copy 5 shall be retained by the exporter as part of his records for a period of at least two years.

PRIVACY ACT INFORMATION
AUTHORITY: Sections 1002 and 1003 of the Controlled Substances Act of 1970 (PL91-513), as amended
(21 U.S.C. 952 and 953).
PURPOSE: To obtain information regarding the importation of nonnarcotic substances in Schedules III, IV, and V and
the exportation of nonnarcotic substances in Schedules III and IV and all substances in Schedule V.
ROUTINE USES: The Controlled Substances Import/Export Declaration produces special reports as required for
statistical and law enforcement purposes. Disclosure of information from this system are made
to the following categories of users for the purposes stated.
A. Other Federal law enforcement and regulatory agencies for law enforcement purposes.
B. State and local law enforcement and regulatory agencies for law enforcement and regulatory
purposes.
EFFECT: Failure to complete this form will preclude requested importation or exportation of the referenced controlled
substances.
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control
number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Drug Enforcement Administration, FOI and Records Management Section, Washington, D.C. 20537; and to the Office of Management and Budget,
Paperwork Reduction Project No. 1117-0009, Washington, D.C. 20503.