SECURITY SCREENING INFORMATION

PERSONNEL WITH ACCESS TO CONTROLLED SUBSTANCES:

Position/Title: ______________________________________

Name: ____________________________________________

Home Address: _____________________________________

_____________________________________

Sex: _______ Race: ________ Height: ________ Weight: _______

Hair Color: _______ Eye color: _______

Social Security Number: ______________ DOB: _____________

DEA # (if applicable): _____________ Driver’s License Number: _________

State License (MD, RN, PHAR etc.): __________________

Expiration Date: ________________

Signature: _____________________

PRIVACY ACT INFORMATION

DEA- 224 Application for Registration (Type A)

DEA- 225 Application for Registration (Type B)

DEA- 363 Application for Registration (Narcotic Treatment)

AUTHORITY: Section 302 and 303 of the Controlled Substance Act of 1970 (PL91-513)

PURPOSE: To obtain information required to register applicants pursuant to the Controlled Substances Act of 1970 (PL 91-513)

ROUTINE USES: The Controlled Substances Act Registration Records produces special reports as required for statistical analytical purposes. Disclosures of information from this system are made of the following categories of users for the purposes stated.

A. Other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes.

B. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.

C. Persons registered under the Controlled Substances Act (PL91-513) for the purpose f verifying the registration of customers and practitioners.

EFFECT: Failure to complete form will preclude processing of the application.

Security.screen.DEA.wpd