DRUG USE STATEMENT

**NAME**: LAST \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ FIRST
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ MIDDLE \_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DIVISION/CONTRACT**:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**SSN**:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**As an applicant for a position with the Drug Enforcement
Administration (DEA), any prior drug use, attempted use, and/or
experimentation must be disclosed before you can be considered for
further processing. Do not include instances in which substances were
prescribed, administered, or dispensed by a duly licensed physician for
treatment of a legitimate medical condition. Please read the following
instructions very carefully before answering the drug questions and
initial your acknowledgment:**

\_\_\_\_\_\_\_ I understand that I must provide truthful information to
DEA regarding all drug use,

(initials) attempted drug use, and/or experimentation of any illegal
narcotics or dangerous drugs

> that have not been prescribed by a duly licensed physician, as well as
> any marijuana usage, regardless of my age or circumstances at the time
> of use, attempted use, and/or experimentation. I understand that I
> will be questioned regarding the information I provide. I understand
> that any omissions or inaccuracies between the information may
> preclude me from further consideration from DEA employment.

\_\_\_\_\_\_\_ I understand that my responses to the drug questions are
to be used to determine

(initials) eligibility and suitability for DEA employment. I also
understand that my answers

> will not be used in any criminal proceedings against me, and that any
> declination to
>
> respond to the drug questions will be noted in my application record.

\_\_\_\_\_\_\_ By the words "*use*," "*attempted use*," and
"*experimentation*," I understand that DEA is (initials) asking me to
disclose any and all experiences with illegal narcotics or dangerous

> drugs, to include any act or attempted act of trying, smoking,
> ingesting, tasting, inhaling, injecting, puffing, or otherwise
> experimenting with a controlled substance or a substance that I
> believe to be a controlled substance.

\_\_\_\_\_\_\_ By the word "*occasion*" I understand that DEA is asking
me to disclose each occasion (initials) or event in which I used,
attempted to use, or experimented with illegal narcotics or

> dangerous drugs, to include marijuana. For example, if I was at a
> party and during the occasion I took a puff on three separate
> marijuana cigarettes, DEA will consider that one use. If I went to
> another party the same night and again puffed on three marijuana
> cigarettes, that would constitute a second use.

\_\_\_\_\_\_\_ I understand that if I answer "yes" to any of the
following questions, I must attach a

(initials) fully comprehensive statement that is typed, signed, and
dated.

**NAME:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SSN: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**[QUESTION 1]{.underline} - Have you ever used, tried, tasted, or
experimented with any illegal narcotics or dangerous drugs to include
marijuana? (Please check) YES ( ) NO ( ) If you answered *YES*, attach a
comprehensive statement fully describing each occasion of drug use,
attempted use, and/or experimentation covering each of questions 1A
through 1H listed below. Your attached statement must be typed, signed,
and dated.**

1A. What was/were the drug(s)?

> 1B. On how many occasions? *NOTE*: If you cannot be specific as to the
> exact number
>
> of occasions, answer the following: On at least \_\_\_\_ occasions,
> but not more than \_\_\_\_.
>
> 1C. Date first used/tried/experimented?
>
> 1D. Date last used/tried/experimented?
>
> 1E. How was it obtained?
>
> 1F. Where was it used/tried/experimented?
>
> 1G. In what setting?
>
> 1H. Reason for use/try/experimentation?

**[QUESTION 2]{.underline} - Have you ever used marijuana that has been
legally prescribed to you by a duly licensed physician? (Please check)
YES ( ) NO ( )**

**[QUESTION 3]{.underline} - Have you ever purchased, furnished,
provided, sold, supplied, manufactured, produced, transported, or
otherwise trafficked in any illegal narcotic or dangerous drug, to
include marijuana? (Please check) YES ( ) NO ( )**

**[QUESTION 4]{.underline} - Have you ever abused or sold any licit
(legal) drugs, chemicals, paraphernalia, or addictive substances, not to
include alcohol?**

**(Please check) YES ( ) NO ( )**

**[QUESTION 5]{.underline} - Have you ever provided drug history
information to the military, your present employer, or a prospective
employer that differs from the drug history information you are now
providing to DEA? (Please check) YES ( ) NO ( )**

**[QUESTION 6]{.underline} - Do you foresee any conflict of interest
between your personal habits and beliefs and the DEA mission, which is
to provide a drug-free environment?**

**(Please check) YES ( ) NO ( )**

**NAME:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SSN: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

If you answered *YES* to any of questions 2-6, attach a comprehensive
statement fully describing all circumstances. Your attached statement
must be typed, signed, and dated.

***I have been fully truthful in my answers and statements to the above
questions and have disclosed all drug use, attempted use, and/or
experimentation during my lifetime.***

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Applicant Signature Date

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Witness Signature Date