21 Code For Federal Regulation Parts 1305, 1311 Page 39
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67I, __________ (name of attorney-in-fact), hereby affirm that I am the person named herein as
attorney-in-fact and that the signature affixed hereto is my signature.
(signature of attorney-in-fact)
Witnesses:
1. ____________.
2. ____________.
Signed and dated on the ______ day of __________, (year), at __________.
Notice of Revocation
The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to
sign the current application for registration of the above-named registrant under the Controlled
Substances Act or the Controlled Substances Import and Export Act. Written notice of this
revocation has been given to the attorney-in-fact __________ this same day.
______________________________________________________________________
(Signature of person revoking power)
Witnesses:
1. ____________.
2. ____________.
Signed and dated on the ______ day of __________, (year), at __________.
(d) A power of attorney must be executed by the person who signed the most recent
application for DEA registration or reregistration; the person to whom the power of attorney is
being granted; and two witnesses.
39
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