Drug Enforcement Administration Power of Attorney Form

Drug Enforcement Administration Power of Attorney Form
Appoint an authorized representative for DEA-related matters. Complete all required fields to grant power of attorney.
Principal’s Full Name
First NameLast Name
Principal’s Email Address
example@example.com
Authorized Representative’s Full Name
First NameLast Name
Authorized Representative’s Email Address
example@example.com
Scope of Authorization (Describe the DEA-related powers granted)
Effective Date
MonthDayYear
Date
Expiration Date (if applicable)
MonthDayYear
Date
Phone Number of Authorized Representative
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Principal
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Should be Empty: