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 Name
Last Name
Principal’s Email Address
*
example@example.com
Authorized Representative’s Full Name
*
First Name
Last Name
Authorized Representative’s Email Address
*
example@example.com
Scope of Authorization (Describe the DEA-related powers granted)
*
Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number of Authorized Representative
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of Principal
*
Submit Power of Attorney
Submit Power of Attorney
Should be Empty: