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Get DoJ DEA-106 2014

Complete the front and back of this form. Make two additional copies of the completed form. Forward the original and duplicate copies to the nearest DEA Office. Retain the triplicate copy for your records. Some states may also require a copy of this report. 2. Phone No. (Include Area Code) 1. Name and Address of Registrant (include ZIP Code) 3. DEA Registration Number 4. Date of Theft or Loss 5. Principal Business of Registrant (Check one) 1 2 3 4 6. County in which Registrant is Located .

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