Dea Form 189 - Application For Individual Manufacturing Quota - 2016

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APPLICATION FOR INDIVIDUAL MANUFACTURING QUOTA
U.S. Department of Justice
Drug Enforcement Administration
No individual manufacturing quota may be issued unless a completed
OMB Approval
SEE INSTRUCTIONS ON
SEPARATE PAGE
application form has been received, 21 CFR 1303.22
No. 1117-0006
1. NAME OF BASIC CLASS OR LIST I CHEMICAL (Only one per DEA–189)
2. SCHEDULE / LIST
3. DEA DRUG / CHEMICAL CODE NUMBER
NUMBER
4. NAME AND ADDRESS OF REGISTRANT (Include No., Street, City, State and ZIP Code)
5. YEAR FOR WHICH QUOTA IS
REQUESTED
6. DEA REGISTRATION NUMBER
7. NAME OF CONTACT PERSON
8. TELEPHONE No. (Include extension)
9. FAX NO.
10. E-MAIL ADDRESS
NOTE: All quantities are to be expressed in grams of anhydrous acid, base, or alkaloid (not as salts).
QUOTAS PREVIOUSLY ISSUED BY DEA
11. QUOTA HISTORY
QUOTA REQUESTED
nd
st
2
PRECEDING YEAR
1
PRECEDING YEAR
CURRENT YEAR
(
)
(
)
(
)
(
)
_________________grams
______________grams
______________grams
______________grams
ESTIMATE FOR YEAR
ND
2
PRECEDING
ESTIMATE
ST
12. PRODUCTION DATA
1
PRECEDING YEAR
FOR WHICH
YEAR
FOR CURRENT YEAR
QUOTA IS REQUESTED
I. INVENTORY AS OF DEC. 31
a. Bulk Controlled Substance or List I Chemical . . . . . .
b. In-process material . . . . . . . . . . . . . . . .
c. Contained in FINISHED Dosage Forms
0
0
0
TOTAL (a + b + c) . . . . . . . . . . . . .
0
II. DISPOSITION (SALE ) / UTILIZATION
a. Domestic . . . . . . . . . . . . . . . . . . . . . . . .
b. Exports . . . . . . . . . . . . . . . . . . . . . . . . .
0
0
0
TOTAL (a + b) . . . . . . . . . . . . . . . .
0
III. ACQUISITION / PRODUCTION
a. Domestic Sources . . . . . . . . . . . . . . . . .
b. Importation . . . . . . . . . . . . . . . . . . . . . . .
0
0
TOTAL (a + b) . . . . . . . . . . . . . . .
0
0
13. IF THE PURPOSE IS TO MANUFACTURE ANOTHER SUBSTANCE(S), FURNISH THE FOLLOWING INFORMATION:
DEA
AUTHORITY
AMOUNT USED FOR THIS PURPOSE
CHEMICAL
NAME OF NEW
% YIELD
TO MARKET
ND
2
PRECEDING
CODE
SUBSTANCE
(Historical)
THIS
ST
1
PRECEDING YEAR
CURRENT YEAR
YEAR
NUMBER
PRODUCT
14. REMARKS
SIGNATURE OF APPLICANT
PRINT or TYPE NAME and TITLE of SIGNER
DATE
DEA FORM 189
(6/29/2016)
ALL PREVIOUS EDITIONS ARE OBSOLETE.
RESET FORM
PRINT FORM

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