DEA Form 189 Application for Individual Manufacturing Quota for a Bas

APPLICATION FOR INDIVIDUAL MANUFACTURING QUOTA

U.S. Department of Justice
Drug Enforcement Administration

No individual manufacturing quota may be issued unless a completed
application form has been received, 21 CFR 1303.22

SEE INSTRUCTIONS ON
SEPARATE PAGE

1. NAME OF BASIC CLASS OR LIST I CHEMICAL (Only one per DEA–189)

OMB Approval
No. 1117-0006

2. SCHEDULE / LIST
NUMBER

3. DEA DRUG / CHEMICAL CODE NUMBER

4. NAME AND ADDRESS OF REGISTRANT (Include No., Street, City, State and ZIP Code)

5. YEAR FOR WHICH QUOTA IS
REQUESTED
6. DEA REGISTRATION NUMBER

7. NAME OF CONTACT PERSON

8. TELEPHONE No. (Include extension)

9. FAX NO.

10. E-MAIL ADDRESS

NOTE: All quantities are to be expressed in grams of anhydrous acid, base, or alkaloid (not as salts).
QUOTAS PREVIOUSLY ISSUED BY DEA

11. QUOTA HISTORY
nd

2 PRECEDING YEAR
(

12. PRODUCTION DATA

1st PRECEDING YEAR

)

(

QUOTA REQUESTED

CURRENT YEAR

)

(

(

)

)

______________grams

______________grams

______________grams

_________________grams

2ND PRECEDING
YEAR

1ST PRECEDING YEAR

ESTIMATE
FOR CURRENT YEAR

ESTIMATE FOR YEAR
FOR WHICH
QUOTA IS REQUESTED

I. INVENTORY AS OF DEC. 31
a. Bulk Controlled Substance or List I Chemical . . . . . .
b. In-process material . . . . . . . . . . . . . . . .
c. Contained in FINISHED Dosage Forms
TOTAL (a + b + c) . . . . . . . . . . . . .

0

0

0

0

0

0

0

0

0

0

0

0

II. DISPOSITION (SALE ) / UTILIZATION
a. Domestic . . . . . . . . . . . . . . . . . . . . . . . .
b. Exports . . . . . . . . . . . . . . . . . . . . . . . . .
TOTAL (a + b) . . . . . . . . . . . . . . . .
III. ACQUISITION / PRODUCTION
a. Domestic Sources . . . . . . . . . . . . . . . . .
b. Importation . . . . . . . . . . . . . . . . . . . . . . .
TOTAL (a + b) . . . . . . . . . . . . . . .

13. IF THE PURPOSE IS TO MANUFACTURE ANOTHER SUBSTANCE(S), FURNISH THE FOLLOWING INFORMATION:

NAME OF NEW
SUBSTANCE

AUTHORITY
TO MARKET
THIS
PRODUCT

DEA
CHEMICAL
CODE
NUMBER

AMOUNT USED FOR THIS PURPOSE
2ND PRECEDING
YEAR

1ST PRECEDING YEAR

% YIELD
(Historical)

CURRENT YEAR

14. REMARKS

SIGNATURE OF APPLICANT

DEA FORM 189

(4/30/2016)

PRINT or TYPE NAME and TITLE of SIGNER

ALL PREVIOUS EDITIONS ARE OBSOLETE.

RESET FORM

PRINT FORM

DATE