161 Application for Permit to Export Controlled Substances

OMB APPROVAL NO. 1117-0004
Expiration Date 9/30/2016
U.S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

APPLICATION FOR PERMIT TO EXPORT CONTROLLED SUBSTANCES
PURSUANT TO SECTION 1003(a), (b), (c) & (d), Title III, PL 91-513
(See Reverse for Instructions and Privacy Act Information)

TO:

DATE

Drug Enforcement Administration
Office of Diversion Control
Import / Export Unit (ODGI)
8701 Morrissette Drive, Springfield, VA 22152

EXPORTER'S APPLICATION NUMBER

Application is hereby made pursuant to the provisions of the Controlled Substances Import and Export Act and the
regulations prescribed thereunder for a permit to export as follows:
1. NAME OF CONSIGNEE

2. ADDRESS OF CONSIGNEE

3. BUSINESS OF CONSIGNEE

4. FOREIGN PORT OF ENTRY (City & Country)

5a. PORT OF EXPORTATION (City & State of last
U.S. Customs port)

5b. NAME OF EXPORTING CARRIER OR VESSEL
(Air, Ship)

6. FOREIGN IMPORT LICENSE OR PERMIT NO.

5c. APPROX. DATE OF EXPORTATION

ISSUE DATE:

7a. NAME AND QUANTITY OF DRUG OR PREPARATION TO
BE EXPORTED (Enter names as shown on labels;
numbers and sizes of packages; strength of tablets,
capsules, etc., CSA Drug Code, and NDC Number)

7b. CONTROLLED SUBSTANCE CONTENT OF DRUG OR
PREPARATION TO BE EXPORTED expressed as acid,
base, or alkaloid (Enter name of controlled substance
contained in the drug, compound, or preparation.)

EXPIRE DATE:
7c. DATE EXPORTED AND ACTUAL
QUANTITY (Completed by
registrant at time of export)
DEA PERMIT NO.:

AFFIDAVIT

The packages to be exported are labeled in conformance with 21 C.F.R. Part 302 and, to the best of my knowledge and belief, the importing country has instituted and
maintains a system for the control of these substances; the drugs are consigned to a holder of such permits or licenses as may be required under the laws of the country of
import; the substances are to be applied exclusively to medical or scientific uses within the country of import; there is an actual need for the controlled substances for
medical or scientific uses within such country; the substances will not be re-exported therefrom; except, in the case of bulk cocaine alkaloid, the substance will be processed
within the country of import and the products therefrom may be re-exported in accordance with Paragraph 2, Article 31 of the Single Convention on Narcotic Drugs, 1961.
ADDRESS OF EXPORTER

NAME OF EXPORTER

EXPORTER’S TELEPHONE NO.

EXPORTER’S DEA REGISTRATION NO.

SIGNATURE AND TITLE OF PERSON MAKING APPLICATION
Print Name:

NOTICE: Controlled Substances may not be exported by mail or parcel post.
DEA USE ONLY
FORM DEA-161

APPROVED EXPORT PERMIT NUMBER

Print Form

DATE EXPORT PERMIT NUMBER ISSUED

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