Please check how controlled substances will be utilized. List the percentages of each. Percentages must equal 100%.
On-site Inspection Contact Name
On-site Inspection Contact Phone
DEA 222 Authorized Signers (other than Registrant)
I, (name of person granting power *), the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint (name of attorney-in-fact *), my true and lawful attorney for me in my name, place, and stead, to execute applications for books of official order forms and to sign such order forms in requisition for Schedule I and II controlled substances, in accordance with section 308 of the Controlled Substances Act (21 U.S.C. 828) and part 305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney shall lawfully do or cause to be done by virtue hereof.
I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.
To be completed only when Power of Attorney is revoked
The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or the
Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact this same day.
I, (name of person granting power *), the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint (name of attorney-in-fact *), my true and lawful attorney for me in my name, place, and stead, to execute applications for books of official order forms and to sign such order forms in requisition for Schedule I and II controlled substances, in accordance with section 308 of the Controlled Substances Act (21 U.S.C. 828) and part 305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney shall lawfully do or cause to be done by virtue hereof.
I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.
To be completed only when Power of Attorney is revoked
The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or the
Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact this same day.
I, (name of person granting power *), the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint (name of attorney-in-fact *), my true and lawful attorney for me in my name, place, and stead, to execute applications for books of official order forms and to sign such order forms in requisition for Schedule I and II controlled substances, in accordance with section 308 of the Controlled Substances Act (21 U.S.C. 828) and part 305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney shall lawfully do or cause to be done by virtue hereof.
I, (name of attorney-in-fact *), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.
To be completed only when Power of Attorney is revoked
The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or the
Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact this same day.
Select ALL state(s) where you dispense Controlled Substances, except your domicile state, and provide your license number(s)
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