Completed Internet Form - NOT FOR SUBMISSION
DEA/Control Number - PT0206501
Submission Date: 11-12-2014
APPLICATION FOR REGISTRATION
UNDER CONTROLLED SUBSTANCES ACT OF 1970
Form DEA 225A - Completed Internet Receipt. NOT FOR SUBMISSION

NAME: Applicant or Business (LAST)

(First, MI)
Application Complete. Internet confirmation no.: 4772962
Fee Paid: $244

TAX IDENTIFYING NUMBER        and/or

SOCIAL SECURITY NUMBER

The Debt Collection Improvement Act of 1996 (PL 104-134) requires that you furnish your federal Taxpayer Identifying Number to DEA. This number is required for debt collection procedures should your fee become uncollectable. IF you do not have a Federal Taxpayer Identifying Number, use your Social Security Number.

PROPOSED BUSINESS ADDRESS. (When entering a P.O. box, you are required to enter a street address)


CITY

STATE         ZIP CODE

    -

APPLICANT'S BUSINESS PHONE NUMBER

APPLICANT'S FAX NUMBER

- - - -
REGISTRATION CLASSIFICATION
1. BUSINESS
   ACTIVITY:
ANALYTICAL LAB
2. INDICATE HERE IF YOU REQUIRE ORDER FORM BOOKS.
3. Drug Schedules. (Fill in all circles that apply)
Schedule I Schedule II
Narcotic
Schedule II
Non Narcotic
Schedule III
Narcotic
Schedule III
Non Narcotic
Schedule IV Schedule V
4. All Applicants must answer the following:

Are you 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 No.    State: OH
Expire Date: 03-31-2015
State Controlled Substance Lic. No.  
Expire Date: --

1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law, or been excluded or directed to be excluded from participation in a medicare or state health care program, or any such action pending?

N

4. 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 or had a federal controlled substance registration revoked, suspended, restricted or 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?
N

2. 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?

N

3. 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?

N

Drug Codes

6. Payment Method: --
Card Number:
Expiration Date:    Fee Paid: 244
7. Certification for Fee Exemption
Certifying Official's Name: N/A  
Certifying Official's Title: N/A  
Certifying Official's Phone: N/A
Application Certification:

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.

By typing my full name in the space below, I hereby certify that the foregoing information furnished on these application/DEA forms pages is true and correct and understand that this constitutes an electronic signature for purposes of these applications/DEA forms only.

* Name of Applicant (For individual registrants, the registrant themselves MUST complete this E-Signature) or name of Officer of the Corporation/Company

    e-Signature:   Benjamin Corpus

This electronic application/DEA form must be certified by the applicant/registrant, if an individual; by a partner of the applicant, if a partnership; or by an officer of the applicant, if a corporation, corporate division, association, trust, or other entity. See 21 C.F.R § 1301.13(j) for more information on who can certify this application

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ADDITIONAL INFORMATION

  • Form 224     Approved OMB Form No. 1117-0014 Expires: 01/31/2016 (12 minutes)
  • Form 225     Approved OMB Form No. 1117-0012 Expires: 04/30/2015 (15 minutes)
  • Form 510     Approved OMB Form No. 1117-0031 Expires: 04/30/2016 (15 minutes)
  • Form 363     Approved OMB Form No. 1117-0015 Expires: 04/30/2015 (15 minutes)
  1. No registration will be issued unless a completed application form has been received (21 CFR 1301.13).
  2. 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 OMB control number. The OMB number for this collection is (See Above). Public reporting burden for this collection of information is estimated to average (See Above) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information.
  3. 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.
  4. 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 principle 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 person 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.

DEA OFFICE OF DIVERSION CONTROL PRIVACY POLICY