Form DEA-236 Controlled Substances Import/Export Declaration

U.S. Department of Justice / Drug Enforcement Administration CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION (Read Instructions on reverse before completing)							OMB APPROVAL No. 1117-0009 EXPIRATION DATE: Date Needed
							See reverse for Privacy Act
1. CHECK ONE	IMPORT DECLARATION	Nonnarcotic Substances in Schedules III, IV, V					U.S. CUSTOMS CERTIFICATION
	EXPORT DECLARATION	Nonnarcotic Substances in Schedules III, and IV and all substances in Schedule V					Date of Departure/Arrival
IMPORTER/EXPORTER (Name and Address)			BROKER OR FORWARDING AGENT, IF USED (Name and Address)				Date of Certification
							Signature of Customs Official
							DEA Transaction ID
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)			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)					2c. DATE IMPORTED/EXPORTED AND ACTUAL QUANTITY (Completed by registrant at time of transaction)
3a. FOREIGN (for U.S. import) DOMESTIC (for U.S. export) PORT OF EXPORTATION AND APPROX. DEPARTURE DATE					3b. FOREIGN (for U.S. export) DOMESTIC (for U.S. import) PORT OF IMPORTATION AND APPROX. ARRIVAL DATE
4a. MODE OF TRANSPORT; NAME OF VESSEL / CARRIER (if known)					4b. NAME OF ALL INTERMEDIATE CARRIERS
5. NAME AND ADDRESS OF FOREIGN CONSIGNEE/CONSIGNOR
I hereby certify that the substance(s) listed in Section 2 are to be Imported (conform to 21 U.S.C. § 952(b)) Exported (conform to 21 U.S.C. § 953(e)) and are intended for Medical, Scientific, or Other legitimate uses (attach explanation for other legitimate use). The above named substances are to be Re-Exported (Attach documentation per Title 21, CFR 1312.27) to (list countries): If the form is being used as an "Export Declaration", attach documentation that the consignee is authorized under the laws and regulations of the country of destination to receive the controlled substances. If the controlled substances are being re-exported from the first country to second countries, attach documentation that the consignee in the country of ultimate destination is authorized under the laws and regulations of that country to receive the controlled substances.
SIGNATURE OF AUTHORIZED INDIVIDUAL OF IMPORTER / EXPORTER, BROKER OR FORWARDING AGENT Print Name:				DATE		NAME OF FIRM AND TELEPHONE NUMBER

DEA FORM–236 COPY 1