Form Not Applicable Not Applicable Controlled Substances Act Registration Data-Use Request

Drug Enforcement Administration Registration CSA Data-Use Request

Access to data from the Drug Enforcement Administration’s Controlled Substances Act Registration Information Database is limited to those complying with Statutes and Rules administered by DEA, as well as other Federal, State, and local, laws and ordinances. Please complete this form to request access to the dataset from the DEA Controlled Substances Act Registration Information Database. Completed form and any supporting documentation must be emailed to DEA.CSARDA@usdoj.gov.

Company Name: ____________________________________ Company Email: _______________________________

First Name: ____________________ Middle Name: ____________________ Last Name: ____________________

Address 1: ________________________________________________________________________________________

Address 2: ________________________________________________________________________________________

City: ________________________________________ State: __________ Zip: __________ Zip+4: __________

Phone: ______________________________ Extension: ____________________

Category you are applying for:

[ ] Full Dataset

• Parent organizations of those entities registered under the Controlled Substance Act.

• Entities with Federal or State statutory requirements.

• Entities providing credentialing or verification services to the Pharmaceutical and Healthcare industry.

[ ] Limited Dataset (Does not contain DEA Numbers or Expiration Dates)

• For those that do not fall into the above category but can demonstrate a Need-to-Know.

Please note that a self-designed system, a system designed by your organization, will be necessary to efficiently use the downloaded text file due to its size and the amount of data contained within the file.

Justification (Describe in detail the proposed use of the dataset applied for. Include Federal and/or State statutory requirements). Use additional pages as necessary.

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DEA Registration Dataset Data-Use Agreement

In order to process your application for access to the DEA Controlled Substances Act Registration Information Database and the dataset contained within, you must agree to the following provisions.

The Drug Enforcement Administration is the owner of the DEA Controlled Substances Act Registration Information Database, and the dataset contained within. Access to the DEA Controlled Substances Act Registration Information Database, and the dataset contained within, is limited to those registered with, or by application to, the Drug Enforcement Administration in order to comply with Federal, State, and local, Statutes and Rules.

The repackaging and/or remarketing of the DEA Controlled Substances Act Registration Information Database, and the dataset contained within, is strictly forbidden without the written consent of the Drug Enforcement Administration.

By your acknowledgement below, you agree to the following:

• Information contained within the dataset will only be used for the approved purposes described in the justification described within this application. Intentional misuse of the information contained within the dataset to include: unauthorized distribution, reverse engineering, re-engineering, profit from the sale, or the incorporation in a software system or package, are subject to criminal prosecution.

• Agree to protect access to the information to prevent any unauthorized use thereof.

• Agree to notify DEA within 24 hours if any provided data is breached and/or disclosed to unauthorized persons.

• Agree to protect the information from any further dissemination and/or unauthorized use.

• Access to the DEA Controlled Substances Act Registration Information Database, and the dataset contained within, is issued on an annual basis. Access must be applied for annually.

My signature confirms that I have read and understood the information and agree to the terms outlined above.

Signature: ___________________________________________________ Date: _______________________________

Printed name: ________________________________________________ Title: _______________________________

WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000, or both.