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

Pharmacist's Manual - APPENDIX A-N

Appendix E

Affidavit for a New Pharmacy1

I, ____________________________, the ________________________ (Title of officer, official, partner, or other position) of _____________________________  (Corporation, partnership, or sole proprietor), doing business as ______________________________ (Store name) at _______________________ (Number and Street), __________________ (City) _______________________ (State) ___________________ (Zip Code), hereby certify that said store was issued a pharmacy permit No. __________________ by the _____________________________ (Board of Pharmacy or Licensing Agency) of the State of ________________________ on _________________________ (Date).

This statement is submitted in order to obtain a Drug Enforcement Administration registration number. I understand that if any information is false, the Administration may immediately suspend the registration for this store and commence proceedings to revoke under 21 U.S.C. § 824(a) because of the danger to public health and safety. I further understand that any false information contained in this affidavit may subject me personally and the above-named corporation/partnership/business to prosecution under 21 U.S.C. § 843, the penalties for conviction of which include imprisonment for up to 4 years, a fine of not more than $30,000.00 or both.
Signature (Person who signs Application for Registration)
State of ___________________ County of _______________ Subscribed to and sworn before me this ________ day of ____________, 20______.
Notary Public

1 21 C.F.R. § 1301.17(a)

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