Form 236 Controlled Substances Import/Export Declaration

Please complete page 1 only. The remaining copies will be generated automatically.
U.S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117-0009
EXPIRATION DATE: 9/30/2016

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION
(Read Instructions on reverse before completing)

1.
CHECK
ONE

See reverse for Privacy Act

IMPORT DECLARATION

Nonnarcotic Substances in Schedules III, IV, V

EXPORT DECLARATION

Nonnarcotic Substances in Schedules III, and IV and all substances in
Schedule V

IMPORTER/EXPORTER (Name and Address)

BROKER OR FORWARDING AGENT, IF USED (Name and
Address)

U.S. CUSTOMS
CERTIFICATION
Date of Departure/Arrival
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)

DEA Transaction ID

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
intended for

Medical,

Scientific, or

Imported (conform to 21 U.S.C. § 952(b))

Exported (conform to 21 U.S.C. § 953(e)) and are

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 /
DATE
NAME OF FIRM AND TELEPHONE NUMBER
EXPORTER, BROKER OR FORWARDING AGENT
Print Name:
DEA FORM–236

COPY 1

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U.S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117-0009
EXPIRATION DATE: 9/30/2016

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION
(Read Instructions on reverse before completing)

1.
CHECK
ONE

See reverse for Privacy Act

IMPORT DECLARATION

Nonnarcotic Substances in Schedules III, IV, V

EXPORT DECLARATION

Nonnarcotic Substances in Schedules III, and IV and all substances in
Schedule V

IMPORTER/EXPORTER (Name and Address)

BROKER OR FORWARDING AGENT, IF USED (Name and
Address)

U.S. CUSTOMS
CERTIFICATION
Date of Departure/Arrival
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)

DEA Transaction ID

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
intended for

Medical,

Scientific, or

Imported (conform to 21 U.S.C. § 952(b))

Exported (conform to 21 U.S.C. § 953(e)) and are

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 /
DATE
NAME OF FIRM AND TELEPHONE NUMBER
EXPORTER, BROKER OR FORWARDING AGENT
Print Name:
DEA FORM–236

COPY 2

U.S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117-0009
EXPIRATION DATE: 9/30/2016

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION
(Read Instructions on reverse before completing)

1.
CHECK
ONE

See reverse for Privacy Act

IMPORT DECLARATION

Nonnarcotic Substances in Schedules III, IV, V

EXPORT DECLARATION

Nonnarcotic Substances in Schedules III, and IV and all substances in
Schedule V

IMPORTER/EXPORTER (Name and Address)

BROKER OR FORWARDING AGENT, IF USED (Name and
Address)

U.S. CUSTOMS
CERTIFICATION
Date of Departure/Arrival
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)

DEA Transaction ID

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
intended for

Medical,

Scientific, or

Imported (conform to 21 U.S.C. § 952(b))

Exported (conform to 21 U.S.C. § 953(e)) and are

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 /
DATE
NAME OF FIRM AND TELEPHONE NUMBER
EXPORTER, BROKER OR FORWARDING AGENT
Print Name:
DEA FORM–236

COPY 3

U.S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117-0009
EXPIRATION DATE: 9/30/2016

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION
(Read Instructions on reverse before completing)

1.
CHECK
ONE

See reverse for Privacy Act

IMPORT DECLARATION

Nonnarcotic Substances in Schedules III, IV, V

EXPORT DECLARATION

Nonnarcotic Substances in Schedules III, and IV and all substances in
Schedule V

IMPORTER/EXPORTER (Name and Address)

BROKER OR FORWARDING AGENT, IF USED (Name and
Address)

U.S. CUSTOMS
CERTIFICATION
Date of Departure/Arrival
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)

DEA Transaction ID

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
intended for

Medical,

Scientific, or

Imported (conform to 21 U.S.C. § 952(b))

Exported (conform to 21 U.S.C. § 953(e)) and are

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 /
DATE
NAME OF FIRM AND TELEPHONE NUMBER
EXPORTER, BROKER OR FORWARDING AGENT
Print Name:
DEA FORM–236

COPY 4

U.S. Department of Justice / Drug Enforcement Administration

OMB APPROVAL
No. 1117-0009
EXPIRATION DATE: 9/30/2016

CONTROLLED SUBSTANCES IMPORT / EXPORT DECLARATION
(Read Instructions on reverse before completing)

1.
CHECK
ONE

See reverse for Privacy Act

IMPORT DECLARATION

Nonnarcotic Substances in Schedules III, IV, V

EXPORT DECLARATION

Nonnarcotic Substances in Schedules III, and IV and all substances in
Schedule V

IMPORTER/EXPORTER (Name and Address)

BROKER OR FORWARDING AGENT, IF USED (Name and
Address)

U.S. CUSTOMS
CERTIFICATION
Date of Departure/Arrival
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)

DEA Transaction ID

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
intended for

Medical,

Scientific, or

Imported (conform to 21 U.S.C. § 952(b))

Exported (conform to 21 U.S.C. § 953(e)) and are

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 /
DATE
NAME OF FIRM AND TELEPHONE NUMBER
EXPORTER, BROKER OR FORWARDING AGENT
Print Name:
DEA FORM–236

COPY 5