DEA Authorized Purchaser Request Form

DEA Authorized Purchaser Request Form
Please read the following information regarding your DEA chemical request.

One or more of the products that you wish to purchase or have purchased in the past is regulated by the Drug Enforcement Administration (DEA). To ensure that we comply with these regulations, we need to verify that we are authorized to sell to you. Please take a moment to answer a few questions to confirm your eligibility. If you qualify, you will be prompted to complete an Authorized Purchaser form.
Account Details

Please complete the below information
Full Name*

First NameLast Name
Email*
Email must be a company email specific to the individual completing this form. Example: purchasing@chemimpex.com is not acceptable; joe@chemimpex.com is acceptable.
Organization/Company/University*

DEA Authorized Purchaser Request Form - Part A
Are you using the DEA regulated product(s) for Internal use only? "Internal use" means the product is used within your company for activities such as manufacturing or research and development. It does not include activities such as reselling or distributing the product in its original form.*

YesNo

DEA Authorized Purchaser Request Form - Part B
Are you taking possession of the DEA regulated products? "Possession" means physically handling, storing, or processing the product.*

YesNo

We apologize, but due to our current DEA registration and federal regulations, we are not authorized to sell DEA-regulated products to you at this time.

DEA Authorized Purchaser Form

Based on your responses, we are authorized to sell to you. However, in accordance with DEA regulations, we must verify the identity of the purchaser. To complete this process, you will need to fill out the DEA Authorized Purchaser Form. Before you begin this form, we recommend reviewing the helpful tips below.
Tip 1: The purchaser is the person who is placing the order. For example, if someone calls on behalf of a principal scientist, that person is considered the purchaser - not the principal scientist, since they are not placing the order.

Tip 2: Federal law requires the verification of all purchasers of DEA-regulated products. To avoid delays, we recommend having the DEA Authorized Purchaser form completed for anyone authorized and likely to place DEA orders on behalf of your company. For example, if Jane from your purchasing department attempts to place an order but only Joe has a form on file, we will not be able to process Janes's order until she completes the form or Joe places the order instead.
Full Name *
Title*
By signing below, I confirm the following

The information provided in this form is true and correct.I am authorized to purchase products on behalf of the organization.I understand that federal law requires this form to be updated annually.
Signature*

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Date*

MonthDayYear
Date

DEA Authorized Purchaser Form

Based on your responses, we are authorized to sell to you. However, in accordance with DEA regulations, we must verify the identity of the purchaser and obtain a DEA certificate. To verify your identity, please complete this DEA Authorized Purchaser Form. Before you begin this form, we recommend reviewing the helpful tips below.
Tip 1: The purchaser is the person who is placing the order. For example, if someone calls on behalf of a principal scientist, that person is considered the purchaser - not the principal scientist, since they are not placing the order.

Tip 2: Federal law requires the verification of all purchasers of DEA-regulated products. To avoid delays, we recommend having the DEA Authorized Purchaser form completed for anyone authorized and likely to place DEA orders on behalf of your company. For example, if Jane from your purchasing department attempts to place an order but only Joe has a form on file, we will not be able to process Janes's order until she completes the form or Joe places the order instead.
Full Name *
Title*
By signing below, I confirm the following

The information provided in this form is true and correct.I am authorized to purchase products on behalf of the organization.I understand that federal law requires this form to be updated annually.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date

Please read the following information regarding your DEA chemical request.