U.S. Department of Justice / Drug Enforcement Administration
２ｋｅ､ｚｋ＾＾＜８＃～ｨ１～､＄ｅ２＜～＃Ｏｄｗｋｚ､＃/＃＜ｹｗｋｚ､＃８＜２＾＄ｚ＄､Ｏｋｅ＃
read＃instructions＃and＃ｗrivacy＃＄ct＃before＃completing ＃ｋｄ１＃＄pproval＃ｅo.＃ - ＃
＜xpiration＃８ate:＃ / / ＃
､ype＃of＃８eclaration: Ｏｄｗｋｚ､＃ ＜ｹｗｋｚ､＃
ｅon-narcotic＃substances＃in＃～chedules＃ＯＯＯ,＃Ｏｳ,＃or＃ｳ＃
ｅon-narcotic＃substances＃in＃～chedules＃ＯＯＯ＃or＃Ｏｳ＃andall＃substances＃in＃～chedule＃ｳ＃
８＜＄＃､ransaction＃ｅo.*:＃
８ate＃of＃Ｏssue:＃ ８ate＃of＃＜xpiration:＃
*､his＃declaration＃is＃not＃deemed＃filed,＃and＃therefore＃is＃not＃valid,＃until＃the＃８rug＃＜nforcement＃＄dministration＃ ８＜＄ ＃has＃issued＃a＃８＜＄＃､ransaction＃number＃ 1b.＃１roker/Ｆorwarding＃＄gent＃ company＃name＃and＃address
1a.＃Ｏmporter/＜xporter＃ ｨ.～.＃company＃name＃and＃address ＃
８＜＄＃ｚegistration＃ｅo.:＃
2.２ontrolled＃～ubstances＃to＃be＃Ｏmported＃or＃＜xported＃ 2a.＃ｅame＃and＃ uantity＃of＃drug＃or＃preparation＃ name＃on＃ labels;＃number＃and＃size＃of＃packages;＃strength＃of＃drug＃or＃ preparation;＃２～＄＃８rug＃２ode;＃ｅ８２＃ｅumber ＃
2b.＃２ontrolled＃substance＃content＃of＃drug/preparation＃and＃
weight＃calculation＃expressed＃in＃base＃and＃acid＃or＃alkaloid＃ 2c.＃ ｚeturn＃Ｏnformation＃see＃instructions ＃
3a.ｗort＃of＃＜xport:
and＃anticipated＃８ate＃of＃８eparture:＃
3b.ｗort＃of＃Ｏmport:
and＃anticipated＃８ate＃of＃＄rrival:＃ .＃ｄode＃of＃､ransport＃and＃name s of＃carrier＃or＃vessel:＃
5.＃Ｆoreign＃２onsignee/２onsignor＃ company＃name＃and＃address ＃ Ｆoreign＃Ｏmport＃ｗermit＃ｅo.:
８ate＃of＃Ｏssue:
８ate＃of＃＜xpiration:
ｚe uired＃for＃ｨ.～.＃exports ＃
ｚeference＃ｅo.:＃
Ｏ＃hereby＃certify＃the＃substances＃listed＃in＃～ection＃2＃are＃to＃be:＃ Ｏmported＃ conforms＃to＃21＃ｨ.～.２.＃§＃952 b ＃ ＜xported＃ conforms＃to＃21＃ｨ.～.２.＃§＃953 e ＃ and＃are＃intended＃for＃ ｄedical＃ ～cientific,＃or＃ ｋther＃legitimate＃uses＃ attach＃explanation＃for＃other＃legitimate＃uses. ＃
､he＃substances＃listed＃in＃～ection＃2＃will＃be＃ｚe-＜xported＃to:＃ attached＃documentation＃per＃､itle＃21＃２.Ｆ.ｚ.＃§＃1312.2 b 5 ＃
Ｏf＃this＃form＃is＃being＃used＃as＃an＃"＜xport＃８eclaration",＃attach＃doucumentation＃the＃consignee＃is＃authorized＃under＃the＃laws＃and＃regulations＃of＃the＃country＃of＃destination＃to＃ receive＃the＃controlled＃substances.＃ Ｏf＃the＃controlled＃substances＃are＃being＃re-exported＃from＃the＃first＃country＃to＃second＃countries,＃attach＃documentation＃the＃consignee s ＃in＃ the＃country＃of＃ultimate＃destination＃is＃authorized＃under＃the＃laws＃and＃regulations＃of＃that＃country＃to＃receive＃the＃controlled＃substances.＃
ｅame＃of＃Ｆirm＃and＃contact＃information＃of＃person＃submitting＃８＜＄＃Ｆorm-236 ～ignatureof＃＄uthorized＃Ｏndividual＃of＃Ｏmporter/＜xporter,＃１roker,＃or＃
Ｆorwarding＃agent＃
ｗrint＃ｅame:＃ ８ate:＃
ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ５６ＧＨＤ５６９ＧＨＤ５６９ＧＨＤ
