Diversion Control Division, US Department of Justice, Drug Enforcement Administration

Narcotic Treatment Programs Best Practice Guideline

APPENDIX B

FORMS

Suggested Format for the Power of Attorney/Notice of Revocation Form:

(see 21 CFR 1305.07)

_______________________________________________________ (Name of registrant)

_______________________________________________________ (Address of registrant)

_______________________________________________________ (DEA registration number)

I, ___________________________________ (name of person granting power), the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint _________________________ (name of attorney-in-fact), my true and lawful attorney for me in my name, place, and stead, to execute applications for books of official order forms and to sign such order forms in requisition for Schedule I and II controlled substances, in accordance with section 308 of the Controlled Substances Act (21 U.S.C. 828) and part 1305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney shall lawfully do or cause to be done by virtue hereof.

_____________________________________________________________________________________________________

(Signature of person granting power)

I, ___________________________________ (name of attorney-in-fact), hereby affirm that I am the person named herein as attorney-in-fact and that the signature affixed hereto is my signature.

_____________________________________________________________________________________________________

(Signature of attorney-in-fact)

Witnesses:

1. ________________________________________.

2. ________________________________________.

Signed and dated on the ______ day of __________, (year), at __________.

Notice of Revocation

The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act of the Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact __________ this same day.

_____________________________________________________________________________________________________

(Signature of person revoking power)

Witnesses:

1. ________________________________________.

2. ________________________________________.

Signed and dated on the ______ day of __________, (year), at __________.

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