Form DEA-510A Renewal Application for Registration

APPROVED 0MB NO 1117-0031
FORM DEA-510A (1-07)
Previous editions are obsolete

RENEWAL APPLICATION FOR REGISTRATION

Eorm-51 0A
Renewa 1

Under the Controlled Substances Act

INSTRUCTIONS

Save time - renew on-line al
1.
2.
3.
4.
5.

www.deadiversion.usdoj.gov

To renew by mail complete this application. Keep a copy for your records
Print clearly, using black or blue ink, or use a typewriter
Mail this form to the address provided in Section 6 or use enclosed envelope
Include the correct payment amount. FEE IS NON-REFUNDABLE
If you have any questions call 800-882-9539 prior to submitting your application

IMPORTANT: DO NOT SEND THIS APPLICATION AND RENEW ON-LINE

MAIL-TO ADDRESS

REGISTRATION INFORMATION
I
'
'

DEA#

REGISTRATION EXPIRES

FEE FOR ONE (1) YEAR IS $1147.00
FEE IS NON-REFUNDABLE

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

I,, I, II,,, I, I,, III,,, I,,, III,,, II,,", 11,,, 11,,, II,,, II,,, 11,,, I
SECTION 1

UPDATE REGISTRATION INFORMATION • Please fill in missing information and make corrections if needed to any data we have on record for your registration

Name 1 ·

City
State:

Zip
Business

Business
Phone
Number:

Number.

Point of
Contact·

Address

Fax

EMAIL

---------------------------------------------------

- - - - - - - - - - - - - -

-------------

Tax Identification Number

DEBT COLLECTION
INFORMATION

See additional information
note #3 on page 4.

Mandatory pursuant
to Debt Collection
Improvements Act

SECTION 2
A.
SCHEDULES

List 1 chemicals

Enter specific codes
on page 2

------------B.
MANUFACTURER
ONLY
Mark the appropriate
box with an 'X' to indicate
if List 1 chemicals
are handled in bulk
or dosage form

----------------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - STAGE 1
Bulk synthesis/extraction

STAGE 2
Dosage form manufacture

- - - - - -

-

-

-

-

-

C.
CHEMICAL
CODES

Listed below are List 1 chemical codes. Check all the chemical codes you handle. and mark if it is bulk or dosage form.
For more information, see our web site at www.deadiversion.usdoj.gov, 21 CFR 1308, or call 1-800-882-9539

If you bulk manufacture a chemical, check the 'BULK?' column after the applicable class code.
If you manufacture the dosage form of a chemical, check the 'DOSAGE?' column after the applicable

LIST 1 CHEMICAL NAME

D

CODE

3,4-Methylenedioxyphenyl-2-Propanone

9809

Anthranilic Acid

8530

Benzaldehyde

8256

Benzyl Cyanide

8735

Ephedrine

8113

Ergonovine

8675

Ergotamine

8676

Ethylamine

8678

Gamma Butyrolactone (GBL)

2011

Hydriodic Acid

6695

Hypophosphorous Acid and Salts

6797

lsosafrole

8704

Methylamine

8520

N-Acetylanthran Hie Acid

8522

N-Methylephedrine

8115

N-Methylpseudoephedrine

8119

Nitroethane

6724

Norpseudoephedrine

8317

Phenylacetic Acid

8791

Phenylpropanolamine

1225

Piperidine

2704

Piperonal

8750

Prop ionic Anhydride

8328

Pseudoephedrine

8112

Red Phosphorus

6795

Safrole

8323

White Phosphorus

6796

BULK? DOSAGE?

WRITE IN ADDITIONAL CODES You may write in additional chemical codes in this section. Attach a separate sheet if needed.

SECTION 3

Enter your state license: information if you are currently authorized to manufacture distribute import, or export the listed chemicals
for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate.

STATE LICENSE

State

Expiration

License Number :

Date :

NOT REQUIRED
by this state

,,,,,._

C,fo,S,

MM -DD- YYYY
What state issued the license ?

SECTION 4
LIABILITY

YES

NO

YES

NO

1. Ha_s the applicant.ever be~n convicted of a crime in connection with listed chemical(s) under state or federal law,
or rs any such action pending?

Date(s) of incident MM-DD-YYYY:
2. Has. the applicant ever surrendere9 (for cause) or had a federal registration revoked, suspended, restricted, or
denied, or 1s any such action pending?

IMPORTANT
Al questions in
this section must
be answered

fi

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

NO

YES

NO

3. Has. the apptjcant ever surrendered (fqr cause) or had a sta~e profes~ional license or registration revoked, suspended,
denied, restricted, or placed on probation, or 1s 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 r::iroprietor been convicted of a crime in connection with
listed chem1cal(s) under state or federal law, or ever surrendered, for cause} or had a federal listed chemical/controlled
registration revoked, suspended, restricte1 denied, or ever had a state proTessional license or controlled substance
substance registration revoked, suspendeu, denied, restricted or placed on probation, or is any such action pending?

Note: ff question 4 does not apply to you, be sure to mark 'NO'.
ft will slow down processing of your application if you leave it blank.

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

-----------------------------------------------------------------------------EXPLANATION OF
Applicants who have
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
return with application

SECTION 5

Location(s) of incident: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Liability question# _ __

"YES" ANSWERS

Nature of incident:

Disposition of incident:

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.
Name of Fee

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 6
METHOD OF
PAYMENT

Check one form of
payment only

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

Discover

Credit Card Number

Master Card

Mail this form with payment to:

Visa
Expiration Da..t•
............

.

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

Sign if paying by
credit card

FEE IS NON-REFUNDABLE

Signature of Card Holder

Printed Name of Card Holder

SECTION 7
APPLICANT'S
SIGNATURE

I certify that the foregoing information furnished on this application is true and correct

Signature of applicant (sign in ink}

Date

Sign in ink
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
. ;:1\ HEN:?..VVAL. P:c1;.;,c; 3

Form-510A

RENEWAL APPLICATION FOR REGISTRATION Supplementary Instructions and Information

SECTION 1. UPDATE REGISTRATION INFORMATION~ Each data field displays the Information we have on record for your registration. Fill in blanks, update
and correct data in the blocks provided. A physical address is required in address line 1; a post office box or continuation of the address may be

entered in address line 2. Fee exempt applicant must list the address of the fee exempt institution in this section. The email address and point of
contact are new data items that are in the process of 0MB approval and will soon be mandatory. They are requested in order to facilitate
communication or as required by inter-agency data sharing requirements. Applicant must enter a valid tax identification number (TIN).
Debt collection information is mandatory pursuant to the Debt Collection Improvement Act of 1996.

IF ALL THE DATA IS CORRECT AND COMPLETE, THEN SKIP TO SECTION 2.
SECTION 2A. SCHEDULES -Applicant is registering for List 1 chemicals on this application. However, applicant must still comply with state requirements;
federal registration does not overrule state restrictions.
2B. MANUFACTURER ONLY - Mark the appropriate box to indicate if you are manufacturing List 1 chemicals in bulk or dosage form.
2C. CHEMICAL CODES -Applicant must check all List 1 chemicals to be handled and indicate if the chemical is in bulk or dosage form.
SECTION 3. STATE UCENSE(S) - Federal registration by DEA is based upon the applicant's compliance with applicable state and local laws. Applicant should
contact the local state licensing authority prior to completing this application. If your state requires a license, provide that information and attach a

copy to this application. IF YOUR STATE DOES NOT REQUIRE A LICENSE, MARK AN 'X' IN THE BOX TO INDICATE IT IS NOT REQUIRED
BY YOUR STATE.
SECTION 4. LIABILITY - Applicant must answer all four questions for the application to be accepted for processing. If you answer "Yes" to a question, provide
an explanation in the space provided. If you answer "Yes" to several of the questions, then you must provide a separate explanation describing the
location, nature, and result of incident for each "Yes" answer. If additional space is required, you may attach a separate page.
SECTION 5. EXEMPTION FROM APPLICATION FEE - Exemption from payment of application fee is lim"ited to federal, state or local government official or
institution. The applicant's superior or agency officer must certify exempt status. The signature, authority title, and telephone number of the
certifying official (other than the applicant) must be provided. The address of the fee exempt institution must appear in Section 1.
SECTION 6. METHOD OF PAYMENT - Indicate the desired method of payment. Make checks payable to "Drug Enforcement Administration". Third-party
checks or checks drawn on foreign banks will not be accepted. FEES ARE NON-REFUNDABLE.
SECTION 7. APPLICANT'S SIGNATURE -Applicant MUST sign in this section or application will be returned. Card holder signature in section 6 does not fulfill
this requirement.

Notice to Registrants Making Payment by Check
Authorization to Convert Your Check: If you send us a check to make your payment, your check will be converted into an electronic fund transfer.
"Electronic fund transfer" is the term used to refer to the process in which we electronically instruct your financial institution to transfer funds from your

account to our account, rather than processing your check. By sending your completed, signed check to us, you authorize us to copy your check and
to use the account information from your check to make an electronic fund transfer from your account for the same amount as the check. If the
electronic fund transfer cannot be processed for technical reasons, you authorize us to process the copy of your check.

Insufficient Funds: The electronic funds transfer from your account will usually occur within 24 hours, which is faster than a check is normally
processed. Therefore, make sure there are sufficient funds available in your checking account when you send us your check. If the electronic
funds transfer cannot be completed because of insufficient funds, we may try to make the transfer up to more two times.
Transaction Information: The electronic fund transfer from your account will be on the account statement you receive from your financial institution.
However, the transfer may be ,n a different place on your statement than the place where your checks normally appear. For example, it may appear
under "other withdrawals" or "other transactions". You will not receive your original check back from your financial institution. For security reasons,

we will destroy your original check, but we will keep a copy of the check for record-keeping purposes.

Your Rights: You should contact your financial institution immediately if you believe that the electronic fund transfer reported on your account
statement was not properly authorized or is otherwise incorrect. Consumers have protections under Federal law called the Electronic Fund
Transfer Act for an unauthorized or incorrect electronic fund transfer.
ADDITIONAL INFORMATION

1 No registration will be issued unless a completed application form has been received (21 CFR 1301.13).
2. In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid 0MB
control number. The 0MB number for this collection is 1117-0031. 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 information.
3. The Debt Collection Improvements Act of 1996 (PL 104-134) requires that you furnish your Taxpayer Identification Number and/or Social Security Number
on this application. This number is required for debt collection procedures if your fee is not collectible.
4

PRIVACY ACT INFORMATION
AUTHORITY:

Section 302 and 303 of the Controlled Substances Act of 1970 (PL91-513) and Debt Collection Improvements Act of 1966 (PL 104-134)
for SSN and/or TIN
PURPOSE:
To obtain information required to register applicants pursuant to the Controlled Substances Act of 1970
ROUTINE USES: The Controlled Substances Act registration system produces special reports as required for statistical analytical purposes.
Disclosures of information from this system are made to the following :
A. Other federal law enforcement and regulatory agencies for law enforcement and regulatory purposes
B. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes
C. Persons registered under the Controlled Substances Act (PL 91-513) for the purpose of verifying registration
EFFECT:
Failure to complete form will preclude processing of the application.

Your Local
DEA Office

CONTACT INFORMATION

ATLANTA DIVISION OFFICE

ATTN: Registration
75 Spring Street SW, Suite 800
ATLANTA, GA 30303
Georgia
North Carolina
South Carolina
Tennessee

All offices are listed on web site
(800, 877, and 888 are toll-free)
(888)869-9935
(888)219-8689
(866)533-6983
(888)219-7898

tNTERNH

www.deadiversion.usdoj.gov
TELEPHONE:

HQ Call Center (800)882-9539
WRITTEN INQUIRIES:

DEA
PO Box 28083
Washington, D.C. 20038-8083