Dea form 106: Fill out & sign online

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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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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (25 Votes)
2014	4.3 Satisfied (96 Votes)
2000	4.3 Satisfied (165 Votes)

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