DEA Form 357 "Application for Permit to Import Controlled Substances for Domestic and/or Scientific Purposes"

This fillable "Dea Form 357 "application for Permit to Import Controlled Substances for Domestic and/Or Scientific Purposes"" is a document issued by the U.S. Department of Justice - Drug Enforcement Administration specifically for United States residents.

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Download DEA Form 357 "Application for Permit to Import Controlled Substances for Domestic and/or Scientific Purposes"

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U.S. Department of Justice / Drug Enforcement Administration
OMB APPROVAL
APPLICATION FOR PERMIT TO IMPORT CONTROLLED SUBSTANCES
No. 1117-0013
FOR DOMESTIC AND/OR SCIENTIFIC PURPOSES
Expiration Date: 9/30/2020
PURSUANT TO SECTION 1002, TITLE III, P.L. 91-513
See reverse for Privacy Act
(Read instructions on reverse before completing)
DATE
DRUG ENFORCEMENT ADMINISTRATION
TO:
IMPORT/EXPORT UNIT (ODGI)
IMPORTER'S APPLICATION NUMBER
8701 MORRISSETTE DR., SPRINGFIELD, VA 22152
Application is hereby made pursuant to the provisions of the Controlled Substances Import and Export
Act and the regulations prescribed thereunder for a permit to import as follows:
1. NAME OF FOREIGN EXPORTER
2. ADDRESS OF FOREIGN EXPORTER
3. FOREIGN PORT OF EXPORTATION
4. PORT OF ENTRY (U.S. Customs port where shipment will
5. LATEST DATE SHIPMENT WILL LEAVE FOREIGN
clear)
PORT
6a. NAME AND QUANTITY OF DRUG PREPARATION TO BE
6b. CONTROLLED SUBSTANCE CONTENT OF DRUG OR
6c. DATE RELEASED AND ACTUAL QUANTITY
IMPORTED (Enter names as shown on labels; numbers
PREPARATION TO BE IMPORTED expressed as acid, base or
(Completed by registrant at time of
and sizes of packages; strength, CSA Drug Code, and
alkaloid (Enter name of controlled substance contained in
import)
NDC Number)
the drug, compound, or preparation)
DEA PERMIT NO:
7a. ASSIGNED QUOTA FOR THIS
7b. TOTAL KG AUTHORIZED ON PERMITS THIS
7c. KG OF 7b. IMPORTED TO DATE
7d. STOCK ON HAND & DATE
YEAR
YEAR
8. IF SUBSTANCE(S) WILL BE IMP0RTED FOR SCIENTIFIC PURPOSES ONLY, PLEASE COMPLETE:
I hereby certify the above controlled substances are imported exclusively for scientific purposes, pursuant to 21 CFR 1312.13(a)(4) (see reverse), as follows:
Signature of Certifying Individual
NAME OF IMPORTER
ADDRESS OF IMPORTER
IMPORTER'S TELEPHONE NO.
DEA REGISTRATION NO.
SIGNATURE AND TITLE OF PERSON MAKING APPLICATION
NOTICE: Controlled Substances may not be imported by mail or parcel post.
DEA USE
APPROVED IMPORT PERMIT NUMBER
DATE IMPORT PERMIT NUMBER ISSUED
ONLY
DEA FORM - 357
Previous editions are OBSOLETE.
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U.S. Department of Justice / Drug Enforcement Administration
OMB APPROVAL
APPLICATION FOR PERMIT TO IMPORT CONTROLLED SUBSTANCES
No. 1117-0013
FOR DOMESTIC AND/OR SCIENTIFIC PURPOSES
Expiration Date: 9/30/2020
PURSUANT TO SECTION 1002, TITLE III, P.L. 91-513
See reverse for Privacy Act
(Read instructions on reverse before completing)
DATE
DRUG ENFORCEMENT ADMINISTRATION
TO:
IMPORT/EXPORT UNIT (ODGI)
IMPORTER'S APPLICATION NUMBER
8701 MORRISSETTE DR., SPRINGFIELD, VA 22152
Application is hereby made pursuant to the provisions of the Controlled Substances Import and Export
Act and the regulations prescribed thereunder for a permit to import as follows:
1. NAME OF FOREIGN EXPORTER
2. ADDRESS OF FOREIGN EXPORTER
3. FOREIGN PORT OF EXPORTATION
4. PORT OF ENTRY (U.S. Customs port where shipment will
5. LATEST DATE SHIPMENT WILL LEAVE FOREIGN
clear)
PORT
6a. NAME AND QUANTITY OF DRUG PREPARATION TO BE
6b. CONTROLLED SUBSTANCE CONTENT OF DRUG OR
6c. DATE RELEASED AND ACTUAL QUANTITY
IMPORTED (Enter names as shown on labels; numbers
PREPARATION TO BE IMPORTED expressed as acid, base or
(Completed by registrant at time of
and sizes of packages; strength, CSA Drug Code, and
alkaloid (Enter name of controlled substance contained in
import)
NDC Number)
the drug, compound, or preparation)
DEA PERMIT NO:
7a. ASSIGNED QUOTA FOR THIS
7b. TOTAL KG AUTHORIZED ON PERMITS THIS
7c. KG OF 7b. IMPORTED TO DATE
7d. STOCK ON HAND & DATE
YEAR
YEAR
8. IF SUBSTANCE(S) WILL BE IMP0RTED FOR SCIENTIFIC PURPOSES ONLY, PLEASE COMPLETE:
I hereby certify the above controlled substances are imported exclusively for scientific purposes, pursuant to 21 CFR 1312.13(a)(4) (see reverse), as follows:
Signature of Certifying Individual
NAME OF IMPORTER
ADDRESS OF IMPORTER
IMPORTER'S TELEPHONE NO.
DEA REGISTRATION NO.
SIGNATURE AND TITLE OF PERSON MAKING APPLICATION
NOTICE: Controlled Substances may not be imported by mail or parcel post.
DEA USE
APPROVED IMPORT PERMIT NUMBER
DATE IMPORT PERMIT NUMBER ISSUED
ONLY
DEA FORM - 357
Previous editions are OBSOLETE.
Save
Print
Reset
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