Form DEA-225 Application For Registration

APPROVED OMB NO 1117-0012
FORM DEA-225 (10-06)
Previous editions are obsolete

APPLICATION FOR REGISTRATION

Form-225

Under the Controlled Substances Act

INSTRUCTIONS

Save time - apply on-line at www.deadiversion.usdoj.gov

DEA OFFICIAL USE:

1. To apply by mail complete this application. Keep a copy for your records.
2. Print clearly, using black or blue ink, or use a typewriter.
3. Mail this form to the address provided in Section 7 or use enclosed envelope.
4. Include the correct payment amount. FEE IS NON-REFUNDABLE.
5. If you have any questions call 800-882-9539 prior to submitting your application.

Do you have other DEA registration numbers?
NO

IMPORTANT: DO NOT SEND THIS APPLICATION AND APPLY ON-LINE.

MAIL-TO ADDRESS

SECTION 1

FEE FOR ONE (1) YEAR - see Section 2
FEE IS NON-REFUNDABLE

Please print mailing address changes to the right of the address in this box.

APPLICANT IDENTIFICATIION

Individual Registration

Name 1

(Last Name of individual -OR- Business or Facility Name)

Name 2

(First Name and Middle Name of individual - OR- Continuation of business name)

YES

Business Registration

Street Address Line 1 (if applying for fee exemption, this must be address of the fee exempt institution)

Address Line 2

City

State

Business Phone Number

Point of Contact

Business Fax Number

Email Address

DEBT COLLECTION
INFORMATION
Mandatory pursuant
to Debt Collection
Improvements Act

SECTION 2
BUSINESS ACTIVITY
Check one
business activity
box only
Researcher See page 4
for required
attachments

Tax Identification Number (if registration is for business)

Analytical Lab...........................fee for one year is $184

Exporter..............................fee for one year is $1147

Researcher w/Sched I..............fee for one year is $184

Importer..............................fee for one year is $1147

Researcher w/Sched II - V........fee for one year is $184

Reverse Distributor.............fee for one year is $1147

Canine Handler.........................fee for one year is $184

Manufacturer......................fee for one year is $2293

Distributor.................................fee for one year is $1147

Manufacturer BULK...........fee for one year is $2293

Schedule I

Check all that apply
Enter drug codes on
page 2.
B. MANUFACTURERS
ONLY
Mark each box with
an 'X' to indicate which
drug schedule is handled
in each manufacturing
stage

Social Security Number (if registration is for individual)

Provide TIN or SSN.
See additional information
note #3 on page 4.

SECTION 3
A. DRUG SCHEDULES

Zip Code

Schedule II Narcotic

Schedule III Narcotic

Schedule IV

Schedule II Non-Narcotic

Schedule III Non-Narcotic

Schedule V

Check this box if you require official order forms - for purchase or transfer of schedule I and II controlled substances.

1 2 2 NON 3 3 NON 4 5

STAGE 1
Bulk synthesis/extraction

1 2 2 NON 3 3 NON 4 5

STAGE 3
Package / Repackage
Label
/ Relabel

1 2 2 NON 3 3 NON 4 5

STAGE 2
Dosage form manufacture

1 2 2 NON 3 3 NON 4 5

STAGE 4
Non-human consumption

narcotic

narcotic

narcotic

narcotic

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narcotic

narcotic

narcotic

narcotic

SECTION 4

You MUST be currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances
in the schedules for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate.

STATE LICENSE(S)
Be sure to include both
state license numbers
if applicable

State
License Number
(required)

Expiration
Date
(required)

What state was this license issued in?
State Controlled Substance
License Number
(if required)

Expiration
Date

What state was this license issued in?

SECTION 5
LIABILITY

/

/

All questions in
this section must
be answered.

1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law,
or is any such action pending?
2. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended,
restricted, or denied, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
3. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration
revoked, suspended, denied, restricted, or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
4. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association,
partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with
controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance
registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance
registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:

EXPLANATION OF
"YES" ANSWERS

Liability question #

/

MM - DD ­ YYYY

Date(s) of incident MM-DD-YYYY:

IMPORTANT

/

MM - DD ­ YYYY

YES

NO

YES

NO

YES

NO

YES

NO

Note: If question 4 does not apply to you, be sure to mark 'NO'.
It will slow down processing of your application if you leave it blank.
Location(s) of incident:

Applicants who have
Nature of incident:
answered "YES" to
any of the four questions
above must provide
a statement to explain
each "YES" answer.
Use this space or attach
a separate sheet and
Disposition of incident:
return with application

SECTION 6

EXEMPTION FROM APPLICATION FEE
Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution,
and is exempt from payment of the application fee.
FEE EXEMPT
CERTIFIER
Provide the name and
phone number of the
certifying official

SECTION 7
METHOD OF
PAYMENT

Signature of certifying official (other than applicant)

Date

Print or type name and title of certifying official

Telephone No. (required for verification)

Check

Make check payable to: Drug Enforcement Administration
See page 4 of instructions for important information.

American Express

Check one form of
payment only

Credit Card Number

Sign if paying by
credit card

Signature of Card Holder

Discover

Master Card

Mail this form with payment to:

Visa

U.S. Department of Justice
Drug Enforcement Administration
P.O. Box 28083
Washington, DC 20038-8083

Expiration Date

FEE IS NON-REFUNDABLE

Printed Name of Card Holder

SECTION 8
APPLICANT'S
SIGNATURE
Sign in ink

I certify that the foregoing information furnished on this application is true and correct.
Signature of applicant (sign in ink)

Date

Print or type name and title of applicant
WARNING: 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, or both.
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