Application for Import Quota for Ephedrine, Pseudoephedrine, and Phenylpropanolamine

WORKSHEET A

U.S. Department of Justice
Drug Enforcement Administration

APPLICATION FOR IMPORT QUOTA FOR EPHEDRINE, PSEUDOEPHEDRINE, AND PHENYLPROPANOLAMINE
PART 12(II)(a) – DOMESTIC DISPOSITION (SALE) / UTILIZATION
Name of Company or Manufacturer

Address

Contact Person

Telephone

FAX

DEA Registration No. (if applicable)

E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).

Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)

Name of Company or Manufacturer

Address

Contact Person

Telephone

FAX

DEA Registration No. (if applicable)

E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).

Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)

Name of Company or Manufacturer

Address

Contact Person

Telephone

FAX

DEA Registration No. (if applicable)

E-Mail:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).

Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)

Name of Company or Manufacturer

Address

Contact Person

Telephone

FAX

DEA Registration No. (if applicable)

Email:
Quantity to be sold (grams) as
anhydrous base
Please provide documentation (purchase
orders, supply agreements, etc.).

Intended Use
(Choose the appropriate letter and place on corresponding line.)
(A) Sale / product launch (B) Product development / research (C) Other (explain)

If you need additional pages, please copy this one and complete.
DEA FORM 488 (Worksheet A)
(September 2006)

RESET FORM

PRINT FORM