21 C.F.R. § 1305.05
Power of Attorney for DEA Forms 222 and Electronic Orders
_______________________________
(Name of registrant)
_______________________________
(Address of registrant)
_______________________________
(DEA registration number)
I, ____________ (name of person granting power), the undersigned, who am authorized to sign the current application for registration of the above-named registrant under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these presents, do make, constitute, and appoint ____ (name of attorney-in-fact), my true and lawful attorney for me in my name, place, and stead, to execute applications for Forms 222 and to sign orders for Schedule I and II controlled substances, whether these orders be on Form 222 or electronic, in accordance with 21 U.S.C. 828 and Part 1305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney must lawfully do or cause to be done by virtue hereof.
_______________________________
(Signature of person granting power)
I, ____________ (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 _____?_________.
21 C.F.R. §1305.05