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Form 106 2000-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the 'Name and Address of Registrant' along with the ZIP Code in the designated fields.
- Provide your phone number, including the area code, followed by your DEA Registration Number.
- Indicate the 'Date of Theft or Loss' and select your 'Principal Business' from the provided options.
- Fill in the county where you are located and specify if the theft was reported to police, including their contact information.
- Detail the type of theft or loss by checking one option and completing any additional required fields based on your selection.
- Complete sections regarding any pharmaceuticals taken, their estimated value, and any identifying marks on containers.
- If applicable, provide details about losses in transit, including carrier information and whether items appeared tampered with.
- Finally, certify that all information is correct by signing and dating at the bottom of the form.
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