161R Application for Permit to Export Controlled Substances f

Print three copies of this form. Follow instructions for appropriate use of each copy.
OMB APPROVAL NO. 1117-0004

9/30/2016

U.S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

APPLICATION FOR PERMIT TO EXPORT CONTROLLED SUBSTANCES
FOR SUBSEQUENT REEXPORT
PURSUANT TO SECTION 1003(f), Title III, PL 109-57
(See Instructions and Privacy Act Information)
DATE:

EXPORTER APPLICATION NUMBER (If applicable)

1. NAME OF CONSIGNEE IN FIRST COUNTRY

2. ADDRESS OF CONSIGNEE IN FIRST COUNTRY

3. BUSINESS OF CONSIGNEE IN FIRST COUNTRY

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

5c. APPROX. DATE OF EXPORTATION

ISSUE DATE:

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 EXPORT OCCURED AND ACTUAL
QUANTITY (Completed and signed by registrant at
time of export and returned within 30 days to DEA.)
DEA PERMIT NO:
DATE ACTUALLY SHIPPED:

SIGNATURE OF RESPONSIBLE COMPANY
OFFICIAL:

8a. NAME OF CONSIGNEE IN SECOND
COUNTRY

FORM DEA 161-R

8b. ADDRESS OF CONSIGNEE IN SECOND
COUNTRY

8c. AMOUNT TO BE REEXPORTED TO SECOND
COUNTRY (Enter name of controlled substances (7b) and
net weight in gms)

OMB APPROVAL NO. 1117-0004

9/30/2014

U.S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

APPLICATION FOR PERMIT TO EXPORT CONTROLLED SUBSTANCES
FOR SUBSEQUENT REEXPORT (page 2)
9a. NAME OF CONSIGNEE IN SECOND
COUNTRY

9b. ADDRESS OF CONSIGNEE IN SECOND COUNTRY

9c. AMOUNT TO BE REEXPORTED TO
SECOND COUNTRY (Enter name of controlled
substances (7b) and net weight in gms)

10a. NAME OF CONSIGNEE IN SECOND
COUNTRY

10b. ADDRESS OF CONSIGNEE IN SECOND COUNTRY

10c. AMOUNT TO BE REEXPORTED TO
SECOND COUNTRY (Enter name of controlled
substances (7b) and net weight in gms)

11a. NAME OF CONSIGNEE IN SECOND
COUNTRY

11b. ADDRESS OF CONSIGNEE IN SECOND COUNTRY

11c. AMOUNT TO BE REEXPORTED TO
SECOND COUNTRY (Enter name of controlled
substances(7b) and net weight in gms)

PLEASE ATTACH ADDITIONAL SHEETS OF FORM DEA 161R OR DOCUMENTATION PER TITLE 21 CFR 1312.22.

AFFIDAVIT
To the best of my knowledge and belief (1) both the first country to which the controlled substance(s) are exported from the United States and the
second country to which the controlled substances are exported are parties to the Single Convention on Narcotic Drugs, 1961, and the Convention
on Psychotropic Substances, 1971; (2) the first and second countries have each instituted and maintain a system for the control of these
substances; (3) the drugs will be consigned to a holder of such permits or licenses as may be required in the country of import and that a permit or
license for importation will be issued for such import into the second country; (4) that the controlled substances will be reexported from the first
country to the second country no later than 180 days after exportation from the United States; (5) the packages are labeled in conformance
with the Single Convention on Narcotic Drugs, 1961 and the Convention on Psychotropic Substances, 1971, and any amendments to these
treaties; (6) the controlled substances are to be applied exclusively to medical, scientific, or other legitimate uses within the second country; and (7)
the controlled substances will not be exported from the second country.
NAME OF EXPORTER

ADDRESS OF EXPORTER

EXPORTER’S TELEPHONE NO.

EXPORTER’S DEA REGISTRATION NO.

PRINTED NAME & SIGNATURE AND TITLE OF PERSOM MAKING APPLICATION

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

FORM DEA 161-R

APPROVED EXPORT PERMIT NUMBER

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DATE EXPORT PERMIT NUMBER ISSUED

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