Dea Form 222 Request Form

                                                                                                                                                                                                W  

 

DEA 222 FORM WILL BE GENERATED AND SENT TO YOU WITHIN 24-48 HOURS OF YOUR REQUEST. PLEASE DO NOT MAIL

 

YOUR NARCOTIC PRODUCTS UNTIL YOU RECIVE THE ACTUAL DEA 222 FORM.

 

Please print and mail a copy of this form with your shipment

Shipper Information

DEA NAME: _________________________________

D/B/A: _________________

DEA No: ______________________

ADDRESS: _____________________________________________________________

DEA EXP DATE: ______________

CITY: ___________________________ STATE: _________ ZIP: ________________

STATE ID#: ___________________

PHONE#: __________________

FAX#: ____________ EMAIL: _____________

BUYING GROUP:______________

Once you receive the DEA 222 FORM, please fill in the “Packages Shipped” column and the “Date Shipped” column. You keep the top

brown copy for your records and mail the green copy to your local DEA Office.

Y

SI.

No of

Sealed

For ARK Rx Returns

Qty

National Drug Code (NDC#)

Name and Strength of the Drug

No.

Pkgs.

(Yes/No)

Use only

1

2

3

4

5

6

7

8

9

10

11

12

13

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17

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19

20

Signature (Authorized Registrant): ___________________________________

Date: ________________

 

ARK   B USINESS   S ERVICES,   I NC  

A MBWE PHARMACEUTICAL SERVICES COMPANY

rd

 

 

2417   3

  A VENUE,   S TE   8 12  

 

 

BRONX,   N Y   1 0451  

 

 

P.   3 47   5 90   2 779       F   9 17   7 37   8 375  

 

 

E.   I NFO@ARKBS.COM