CSOS Reporting EDI Account Request Form
Section 1 - Organization Information
Date
Company DEA Registration number(s) to be included in the CSOS Reporting Program
Section 3 -- Applicant/Notary Signature
Applicant Signature ___________________________________________________________ Date __________
Organization Contact Name
Phone
Contact Name
Phone
City
In order to adequately protect the information provided to DEA in CSOS EDI transaction reports, participants must take
responsibility for safeguarding assigned user names and passwords. Additionally, participants are asked to immediately notify
the DEA of changes in personnel and account information to insure the integrity of the CSOS EDI system.
Section 2 - CSOS Reporter Information
Printed Name ___________________________________________________________
DEA Diversion E-Commerce Support toll free number: 1-877-332-3266
Is your organization a registered central reporter?
Yes No
Address
E-Mail Address
State
Zip Code
Organization Name
