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Application for Procurement Quota

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Drug Enforcement Administration

SEE INSTRUCTIONS ON SEPARATE PAGE

No procurement quota may be issued unless a completed application form has been received, 21 CFR 1303.12(b)

OMB Approval No. 1117-0008

1. NAME OF BASIC CLASS OR LIST I CHEMICAL (Only one per DEA–250) 2. SCHEDULE / LIST NUMBER

3. DEA DRUG / CHEMICAL CODE NUMBER

4. NAME AND ADDRESS OF REGISTRANT (Include No., Street, City, State and ZIP Code) 5. YEAR FOR WHICH QUOTA IS REQUESTED

6. DEA MANUFACTURING REGISTRATION NUMBER

7. NAME OF CONTACT PERSON 8. TELEPHONE No. (Include extension) 9. FAX No. 10. E-MAIL ADDRESS

NOTE: All quantities are to be expressed in grams of anhydrous acid, base, or alkaloid (not as salts).

11. QUOTA HISTORY QUOTAS PREVIOUSLY ISSUED BY DEA

QUOTA REQUESTED

( )

_________________grams 2nd

PRECEDING YEAR ( )

1st

PRECEDING YEAR ( )

CURRENT YEAR ( )

______________grams ______________grams ______________grams

12. PRODUCTION DATA 2ND PRECEDING YEAR 1ST PRECEDING YEAR ESTIMATE FOR CURRENT YEAR

ESTIMATE FOR YEAR FOR WHICH QUOTA IS REQUESTED I. INVENTORY AS OF DEC. 31

a. Bulk Controlled Substance or List I Chemical . . . . b. In-process material . . . .

c. Contained in FINISHED Dosage Forms TOTAL (a + b + c) . . . II. DISPOSITION (SALE ) / UTILIZATION

a. Domestic . . . . b. Exports . . . . TOTAL (a + b) . . . III. ACQUISITION / PRODUCTION

a. Domestic Sources . . . . b. Importation . . . . TOTAL (a + b) . . .

13. IF THE PURPOSE IS TO MANUFACTURE ANOTHER SUBSTANCE(S), FURNISH THE FOLLOWING INFORMATION:

NAME OF NEW SUBSTANCE

DEA CHEMICAL

CODE NUMBER

AMOUNT USED FOR THIS PURPOSE

% YIELD (Historical) 2ND PRECEDING YEAR 1ST PRECEDING YEAR CURRENT YEAR

14. IF THE PURPOSE IS TO MANUFACTURE THE BASIC CLASS OR LIST I CHEMCIAL INTO DOSAGE FORMS, FURNISH THE FOLOWING INFORMATION:

NAME OF DOSAGE FORM (include product form,

i.e., tablets, patches,

AUTHORITY TO MARKET

THIS PRODUCT

VFKHGXOH#2# OLVW#

AMOUNT USED FOR THIS PURPOSE

2ND PRECEDING YEAR 1ST PRECEDING YEAR ESTIMATE FOR

CURRENT YEAR QUOTA IS REQUESTED ESTIMATE FOR YEAR etc. and strengths)

SIGNATURE OF APPLICANT PRINT or TYPE NAME and TITLE of SIGNER DATE

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