Appendix G

Example of DEA Form-224b
AFFIDAVIT FOR CHAIN RENEWAL
DEA Retail Pharmacy Registrations

No registration may be issued unless a completed application form has been received (21 CFR 1301.13). This affidavit is provided in lieu of a separate DEA application form for each registration on the attached list.

I hereby certify that the answers to the questions below pertain to each of the (# of registrations) registrations on the attached list in the category of retail pharmacy for the (Corporate name) Corporation.

(a) Are the listed locations currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle controlled substances in the schedules for which they currently are authorized on their DEA registration under the laws of the State or jurisdiction in which they are operating?                          [ ] Yes          [ ] No

(b) Has the applicant ever been convicted of a crime in connection with controlled substances under State or Federal law, or ever surrendered or had a State professional license or controlled substance registration revoked, suspended, denied, restricted, or placed on probation, or is any such action pending against the applicant? [ ] Yes       [ ] No

(c) If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association, partnership, or pharmacy, has any officer, partner, stockholder or proprietor been convicted of a crime in connection with controlled substances under State or Federal law, or ever surrendered or had a Federal controlled substance registration revoked, suspended, restricted or denied, or ever had a State professional license or controlled substance registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending against the applicant?          [ ] Yes      [ ] No

IF THE ANSWER TO QUESTION (b) or (c) IS YES FOR ANY LOCATION, INCLUDE A STATEMENT EXPLAINING SUCH RESPONSE(S).

*This illustration may not be used as an actual form.