DEA Form 224A - Completed PDF

9/24/2019 DEA Form 224A - Completed
Form DEA 224A -

Completed Internet Form - NOT FOR SUBMISSION
APPLICATION FOR REGISTRATION Completed Internet
DEA/Control Number - FN6168377
UNDER CONTROLLED SUBSTANCES ACT OF 1970 Receipt. NOT FOR
Submission Date: 09-24-2019
SUBMISSION
Application Complete.
NAME: A B (LAST) (First, MI) Internet confirmation
NUNEZ JACQUELINE MD no.: 8617031
Fee Paid: $731.00
TAX IDENTIFYING NUMBER / SOCIAL SECURITY NUMBER T D C
I A 1996 (PL
104-134)
XXX-XX-5969 T I N
DEA. T
PROPOSED BUSINESS ADDRESS. (W P.O. , )

. IF
F
T I N ,
17201 CIVIC ST NE S S
N .
CITY STATE ZIP CODE
OKEECHOBEE FL 34974 - 2729

APPLICANT'S BUSINESS PHONE NUMBER POC CELL PHONE NUMBER
863 - 763 - 0271 561 - 513 - 5080

POC NAME POC EMAIL
[email protected]
- -
REGISTRATION CLASSIFICATION
2. INDICATE
1. HERE IF YOU
BUSINESS PRACTITIONER-DW/30 REQUIRE
ORDER
ACTIVITY:
FORMS.
3. Drug Schedules. (Fill in all circles that apply)
Schedule Schedule II Schedule III Schedule III Schedule IV Schedule V

II Non Narcotic Narcotic Non Narcotic
Narcotic
Practitioner Details
National Provider ID
* Degree MEDICAL DOCTOR
* Birthdate 03 (Mar) 12 1973
* Graduation Year 2000
* Professional School UMDNJ - UNIVERSITY OF MEDICINE A
4. All Applicants must answer the following:

Are you currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances in the
schedules for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate?
State License No. ME 126589 State: FL

Expire Date: 01-31-2020
State Controlled Substance Lic. No.
Expire Date: --
1. Has the applicant ever been convicted of a crime in 4. If the applicant is a corporation (other than a
connection with controlled substance(s) under state or corporation whose stock is owned and traded by the
federal law, or been excluded or directed to be excluded N public), association, partnership, or pharmacy, has
from participation in a medicare or state health care any officer, partner, stockholder or proprietor been
program, or any such action pending? convicted of a crime in connection with controlled
2. Has the applicant ever surrendered (for cause) or had a substance(s) under state or federal law, or ever
federal controlled substance registration revoked, surrendered or had a federal controlled substance
suspended, restricted or denied, or is any such action N registration revoked, suspended, restricted or
pending? denied, or ever had a state professional license or
controlled substance registration revoked,
3. Has the applicant ever surrendered (for cause) or had a suspended, denied, restricted, or placed on
state professional license or controlled substance probation, or is any such action pending?
registration revoked, suspended, denied, restricted, or N
N
placed on probation, or is any such action pending?
6. Payment Method: --
Card Number: Expiration Date: Fee Paid: 731.00
7. Certification for Fee Exemption

Certifying Official's Name:
https://apps.deadiversion.usdoj.gov/webforms/printHTML.do 1/3
N/A
Certifying Official's Title: N/A
Certifying Official's Phone: N/A
Application Certification:
WARNING: 21 USC 843(d), states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of
imprisonment of not more than 4 years, and a fine under Title 18 of not more than $250,000, or both.
By typing my full name in the space below, I hereby certify that the foregoing information furnished on this electronic DEA application is true and correct
and understand that this constitutes an electronic signature for purposes of this electronic DEA application only.
* Name of Applicant (For individual registrants, the registrant themselves MUST complete this E-Signature) or name of Officer of the Corporation/Company
e-Signature: Jacqueline Nunez
This electronic DEA application must be certified by the applicant/registrant, if an individual; by a partner of the applicant, if a partnership; or by an officer
of the applicant, if a corporation, corporate division, association, trust, or other entity. See 21 C.F.R § 1301.13(j) for more information on who can certify
this application
ADDITIONAL INFORMATION
1. No registration will be issued unless a completed application form has been received (21 CFR 1301.13).
2. In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control
number. The OMB number for this collection is (See Above). Public reporting burden for this collection of information is estimated to average (See Above) per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the information.
3. The Debt Collection Improvements Act of 1996 (31 U.S.C. §7701) requires that you furnish your Taxpayer Identification Number (TIN) or Social Security Number
(SSN) on this application. This number is required for debt collection procedures if your fee is not collectible.
4. PRIVACY ACT NOTICE:
Providing information other than your SSN or TIN is voluntary; however, failure to furnish it will preclude processing of the application. The authorities for
collection of this information are §§302 and 303 of the Controlled Substances Act (CSA) (21 U.S.C. §§822 and 823). The principle purpose for which the
information will be used is to register applicants pursuant to the CSA. The information may be disclosed to other Federal law enforcement and regulatory
agencies for law enforcement and regulatory purposes, State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes,
and person registered under the CSA for the purpose of verifying registration. For further guidance regarding how your information may be used or disclosed,
and a complete list of the routine uses of this collection, please see the DEA System of Records Notice "Controlled Substances Act Registration Records" (DEA-
005), 52 FR 47208, December 11, 1987, as modified.
DIVERSION CONTROL PRIVACY POLICY

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9/24/2019 DEA Form 224A - Completed

Form DEA 224A -

PROPOSED BUSINESS ADDRESS. (W P.O. , )

CITY STATE ZIP CODE

OKEECHOBEE FL 34974 - 2729

863 - 763 - 0271 561 - 513 - 5080

3. Drug Schedules. (Fill in all circles that apply)

Schedule Schedule II Schedule III Schedule III Schedule IV Schedule V

* Degree MEDICAL DOCTOR

* Birthdate 03 (Mar) 12 1973

* Graduation Year 2000

* Professional School UMDNJ - UNIVERSITY OF MEDICINE A

4. All Applicants must answer the following:

State License No. ME 126589 State: FL

7. Certification for Fee Exemption

e-Signature: Jacqueline Nunez

DIVERSION CONTROL PRIVACY POLICY

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