224A Application for Registration Renewal

Under the Controlled Substances Act

INSTRUCTIONS

Save time - renew on-line at www.deadiversion.usdoj.gov
1. To renew by mail complete this application. Keep a copy for your records.
2. Mail this form to the address provided in Section 6 or use enclosed envelope.
3. The "MAIL-TO ADDRESS" can be different than your "PLACE OF BUSINESS" address.
4. 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

SECTION 1

APPROVED OMB NO 1117-0014
FORM DEA-224A (10-20)

RENEWAL APPLICATION FOR REGISTRATION

Form-224A
Renewal

REGISTRATION INFORMATION:
DEA #
REGISTRATION EXPIRES
FEE IS NON-REFUNDABLE

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

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 :

Name 2 :

PLACE OF
BUSINESS

Street
Address
Line 1 :

PLACE OF
BUSINESS

Address
Line 2 :
City
State :
Zip

Business
Phone
Number :

Cell
Phone
Number :

Point of
Contact :

EMAIL
Address :

DEBT COLLECTION
INFORMATION

Social Security Number (if registration is for individual)

Mandatory pursuant
to Debt Collection
Improvements Act

FOR
Practitioner
or
MLP
ONLY:

Tax Identification Number (if registration is for business)

Provide SSN or TIN.
See additional information
note #3 on page 4.

Professional
Degree :
select from
list only

Professional
School :

Year of
Graduation :

National Provider Identification:

Date of Birth (MM-DD-YYYY):
M M

SECTION 2
DRUG SCHEDULES

Check this box if you wish to register for the same schedule(s):

D D

Y

Y Y

Y

Check this box if you require official order forms:
For purchase of schedule 2 controlled substances

NO CHANGE
-OR
CHANGE

If you want to make a change, check all the schedules that you are requesting for this registration:
Schedule 2 Narcotic

Schedule 3 Narcotic

Schedule 4

Schedule 2 Non-Narcotic (2N)

Schedule 3 Non-Narcotic (3N)

Schedule 5

224A RENEWAL - Page 1

SECTION 3

You MUST be currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances
in the schedules 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 License Number

MANDATORY

/
/
Expiration Date: _______________
MM - DD - YYYY

Which state or jurisdiction issued this license?

LIABILITY (All questions in this section must be answered.)

SECTION 4

YES

NO

1. Has the applicant ever been convicted of a crime in connection with controlled substances(s) under state or federal law or is any such action
pending?
Date(s) of incident MM-DD-YYYY: _________________________________

YES

NO

2. Has the applicant ever been excluded or directed to be excluded from participation in a Medicare or state health care program, or is any such
action pending?
Date(s) of incident MM-DD-YYYY: _________________________________

YES

NO

3. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended, restricted, or denied
or is any such action pending?
Date(s) of incident MM-DD-YYYY: _________________________________

YES

NO

4. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration revoked, suspended,
denied, restricted, or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY: _________________________________

YES

NO

5. 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 proprietor been convicted of a crime in connection with controlled substance(s) under state
or federal law, or ever surrendered, for cause, or had a federal controlled substance registration revoked, suspended, restricted, denied, or
ever had a state professional license or controlled substance registration revoked, suspended, denied, restricted or placed on probation, or is
any such action pending?
Date(s) of incident MM-DD-YYYY: _________________________________

EXPLANATION OF
"YES" ANSWERS
Applicants who have
answered “YES” to
any question above
must provide an
explanation.

Liability question #

Note: If question 5 does not apply to you, be sure to mark 'NO'.

Location(s) of incident:

Nature of incident (if necessary, attach a separate sheet and return with application):

Result of incident:

SECTION 5

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.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

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

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

Check one form of
payment only

Credit Card Number

Sign if paying by
credit card

Signature of Card Holder

Discover

Master Card

Mail this form with payment to:

Visa

DEA Headquarters
ATTN: Registration Section/DRR
P.O. Box 2639
Springfield, VA 22152-2639

Expiration Date

FEE IS NON-REFUNDABLE

Printed Name of Card Holder

SECTION 7
APPLICANT'S
SIGNATURE
Sign in ink

I certify that the foregoing information furnished on this application is true and correct.
Signature of applicant (sign in ink)

Date

Print or type name and title of applicant
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.
224A RENEWAL - Page 2

SECTION 3
STATE LICENSE(S)
MANDATORY
Be sure to include both
state license numbers

You MUST be currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances
in the schedules for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate.
State License Number

Expiration
Date

/
/
MM - DD - YYYY

State Controlled Substance
License Number

Expiration
Date

/
/
MM - DD - YYYY

Which state or jurisdiction issued these licenses?

SECTION 4

LIABILITY (All questions in this section must be answered.)
1. Has the applicant ever been convicted of a crime in connection with controlled substances(s) under state or federal law or is any such action
pending?
Date(s) of incident MM-DD-YYYY: _________________________________
2. Has the applicant ever been excluded or directed to be excluded from participation in a Medicare or state health care program, or is any such
action pending?
Date(s) of incident MM-DD-YYYY: _________________________________
3. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended, restricted, or denied or
is any such action pending?
Date(s) of incident MM-DD-YYYY: _________________________________
4. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration revoked, suspended,
denied, restricted, or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY: _________________________________

5. 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 proprietor been convicted of a crime in connection with controlled substance(s) under state or
federal law, or ever surrendered, for cause, or had a federal controlled substance registration revoked, suspended, restricted, denied, or ever
had a state professional license or controlled substance registration revoked, suspended, denied, restricted or placed on probation, or is any
such action pending?
Date(s) of incident MM-DD-YYYY: _________________________________ Note: If question 5 does not apply to you, be sure to mark 'NO'.
EXPLANATION OF
"YES" ANSWERS
Applicants who have
answered “YES” to
any question above
must provide an
explanation.

SECTION 5

Liability question #______

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

Location(s) of incident:___________________________

Nature of incident (if necessary, attach a separate sheet and return with application):

Result 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.

Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

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

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

Check one form of
payment only

Credit Card Number

Sign if paying by
credit card

Signature of Card Holder

Discover

Mastercard

Mail this form with payment to:

Visa

DEA Headquarters
ATTN: Registration Section/DRR
P.O. Box 2639
Springfield, VA 22152-2639

Expiration Date

FEE IS NON-REFUNDABLE

Printed Name of Card Holder

SECTION 7
APPLICANT'S
SIGNATURE
Sign in ink

I certify that the foregoing information furnished on this application is true and correct.
Signature of applicant (sign in ink)

Date

Print or type name and title of applicant
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.
224A RENEWAL - Page 2

Form-224A RENEWAL APPLICATION FOR REGISTRATION Supplementary Instructions and Information
- CONTINUED -

SECTION 3. STATE LICENSE($) - 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 separate controlled substance number, provide that number on this application.
SECTION 4. LIABILITY - Applicant must answer all five 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 questions, then you must provide a separate explanation describing the date, location,
nature, and result of each incident.
If the "Yes" box is already marked, then we have that data on record from a previous registration. You must provide an
explanation for the original and all subsequent [new] incidents. If additional space is required, you may attach a separate
page.
SECTION 5. EXEMPTION FROM APPLICATION FEE - Exemption from payment of application fee is limited 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 in 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
No registration will be issued unless a completed application has been received (21 CFR 1301.13).
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 1117-0014. Public reporting burden for this collection of information is estimated to
average 12 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.
The Debt Collection Improvements Act of 1996 (31 U.S.C.§ 7701) requires that you furnish your Taxpayer Identification Number (TIN) or Social
Security Number (SSN) on this application. This number is required for debt collection procedures if your fee is not collectible.
PRIVACY ACT NOTICE: Providing information other than your SSN or TIN is voluntary; however, failure to furnish it will preclude processing of the
application. The authorities for collection of this information are§§ 302 and 303 of the Controlled Substances Act (CSA) (21 U.S.C.§§ 822 and 823).
The principal purpose for which the information will be used is to register applicants pursuant to the CSA. The information may be disclosed to other
Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes, State and local law enforcement and regulatory
agencies for law enforcement and regulatory purposes, and persons registered under the CSA for the purpose of verifying registration. For further
guidance regarding how your information may be used or disclosed, and a complete list of the routine uses of this collection, please see the DEA
System of Records Notice "Controlled Substances Act Registration Records" (DEA-005), 52 FR 47208, December 11, 1987, as modified.

Your Local
DEA Office

CONTACT INFORMATION

INTERNET:

All offices are listed on web site
(800, 877, and 888 are toll-free)

TELEPHONE :

www.deadiversion.usdoj.gov
HQ Call Center (800)882-9539

WRITTEN INQUIRIES:
DEA
Attn: Registration Section/DRR
PO. Box 2639
Sp ringfield, VA 22152-2639