DEA 104.pdf

DEA 104

1. U.S.Department ofJ••tIce•DrugEnforcementAdministration
VOLUNTARY SURRENDER OFCONTROLLED
SUBSTANCES PRIVILEGES
DEAUSEONLY
FileNo.
MM-09-2034
Afterbeingfullyadvised ofmyrights,andunderstandingthatIamnotrequiredtosurrendermycontrolled
substancesprivileges,Ifreelyexecutethisdocumentandchoosetotaketheactionsdescribedherein.
~ viewofmyallegedfailuretocomplywiththeFedenlrequirementspertainingtocontrolled
substances,andasanindicationofmygoodfaithindesiringtoremedyanyincorrectorunlawful
practicesonmypart;
oInviewofmydesiretoterminatehandlingofcontrolledsubstanceslistedinschedule(s) _
IherebyvoluntarilysurrendermyDrugEnforcementAdministrationCertificateofRegistration,unused.order
forms,andallmycontrolledsubstanceslistedinschedule(s)JC-':L jlSev~nceofmyagreementto
relinquishmyprivilegetohandlecontrolledsubstanceslistedinschedule(s).1L-:Y:. .Further,Iagree
andconsentthatthisdocumentshallbeauthorityfortheAdministratoroftheDrugEnforcement
Administrationtotenninateandrevokemyregistrationwithoutanordertoshowcause,ahearing,oranyother
proceedings.(andifnotallcontrolledsubstancesprivilegesaresurrendered,beissuedanewregistration
certificatelimitedtoschedule(s)N/A ).
Iwaiverefundofanypaymentsmadebymeinconnectionwithmyregistration.
IunderstandthatIwillnotbepennittedtoorder,manufacture,distribute,possess,dispense,administer,
prescribe, orengageinanyothercontrolledsubstanceactivitieswhatever, untilsuchtimeasIamagain
properlyregistered.
NAMEOFREGISTRANT (Print)
Gloria E.Vigil,NP
ADDRESS OFREGISTRANT
ClinicadelaGloria
1720BridgeBlvdSE,Suite H&I
Albuquerque, NewMexico87105
DEAREGISTRATION NO.
MVQ09651S
SIGNATURE OFREGISTRANT ORAUTHORIZED INDIVIDUAl
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NAMEANDDATE
,/a\J10 ~4-~~Q J_n:lk6~·C\o.--\oY
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PRlVACYACT
AUTHORITY: Section301oftheControlledSubstancesActof1970(PL91-513).
PURPOSE: Permitvoluntarysurrender ofcontrolledsubstances.
ROUTINE USES:TheControlledSubstancesAdRegistration Recorusproducesspecialreportsasrequiredforstatistical
analyticalpurposes. DisclosuresofinformationfromthissystemaremadetothefoUoWingcategoriesofusersfor
thepurposesstated:
A.otherFederallawenforcementandrwgulatoryagenclesforlawenforcementandregUlatorypurposes.
B.Stateandlocallawenfon:ementandrwgulatoryagenciesforlawenforcementandregulatorypurposes.
C.PersonsregisteredundertheControlledSubstancesAct(publicLaw91-513)forthepurposeofverifying
theregistrationofcustomersandpractitioners.
EFFECT: FaHuretoprovidetheinfolmationwinhavenoeffectontheindividual.