161r-eea Re-exports Among European Economic Area (eea) Members

OMB APPROVAL NO.

Exp

U.S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

RE-EXPORTS AMONG EUROPEAN ECONOMIC AREA (EEA) MEMBERS
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:

EXPIRE 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.)

7c. DATE RELEASED 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:

PLEASE ATTACH ADDITIONAL SHEETS OF FORM DEA 161R-EEA 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 countries to
which the controlled substances are re-exported are parties to the Single Convention on Narcotic Drugs, 1961, and the Convention on Psychotropic Substances,
1971, and have each instituted and maintain a system for the control of these substances, and are members of the European Economic Area (EEA); (2) the
controlled substance(s) is consigned to a holder of such permits or licenses and a permit or license has been issued by the country of import; (3) the controlled
substance(s) is to be consigned to a holder of such permits or licenses and a permit or license is to be issued by the subsequent countries of import; (4) 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; and (5) the controlled substances are to applied exclusively to medical, scientific, or other legitimate uses with the EEA
countries.
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.
APPROVED EXPORT PERMIT NUMBER

DEA USE ONLY
FORM DEA 161R - EEA

DATE EXPORT PERMIT NUMBER ISSUED

OMB APPROVAL NO.

Exp

U.S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

APPLICATION RE-EXPORTS AMONG EUROPEAN ECONOMIC AREA (EEA) MEMBERS (cont.)
8a.

8b.

8c.

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME AND ADDRESS OF IMPORTING COMPANY

NAME AND BASE WEIGHT OF CONTROLLED SUBSTANCE
(GRAMS)

DATE OF RE-EXPORTED

NAME OF U.S. EXPORTER AND DEA REGISTRATION SIGNATURE OF COMPANY OFFICIAL
NUMBER

Print Name:

FORM DEA 161R - EEA

DEA PERMIT NUMBER