Applicant Signature - Type name of applicant. Print the completed form and sign it. I understand that the number will be used for prescribing and administering only and cannot be used for purchasing or storing of controlled substances. I understand that the DEA number will be voluntarily surrendered upon separation from military service and a separate DEA number is required for work outside official military duty. I surrender my DEA certificate of registration.
Certificate of registration is attached.
Submitting the applications early in the month is encouraged to allow the DEA time to process applications throughout the months indicated.