Completed Internet Form - NOT FOR SUBMISSION
DEA/Control Number - PT0206501
Submission Date: 10-06-2010
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.: 2349040
Fee Paid: $184

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: 12-31-2010
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 is any such action pending?

N

4. If the applicant is a corporation (other than a corporation whose stock is owned or traded by the public), association, partnership, or pharmacy, has any officer, partner, stockholder or proprietor been convicted of a crime in connection with controlled substances under state or federal law, or ever surrendered, for cause, 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: 184
7. Certification for Fee Exemption
Certifying Official's Name: N/A  
Certifying Official's Title: N/A  
Certifying Official's Phone: N/A

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