DEA POWER OF ATTORNEY PUBHEALTH.PDF

Power of Attorney for DEA Forms 222 and Electronic Orders
(Name of registrant): Maricopa County, by and through its Department of Public Health,
Pharmacy, located at 1645 E Roosevelt Street, Phoenix, AZ 85006
(Address of registrant): 4041 N Central Avenue, Suite 1400, Phoenix, AZ 85021
(DEA registration number): AM598…
I, Steve Chucri, Chairman of the Maricopa County Board of Supervisors (name of granting power),the
undersigned, who am authorized to sign the current application for registration of the above-named registrant
under the Controlled Substances Act or Controlled Substances Import and Export Act, have made, constituted,
and appointed, and by these presents, do make, constitute, and appoint Jason Peters, Pharmacy Supervisor
(name of attorney-in-fact), my true and lawful attorney for me in my name, place, and stead, to execute
applications for Forms 222 and to sign orders for Schedule I and II controlled substances, whether these orders
be on Form 222 or electronic, in accordance with 21 U.S.C. 828 and Part 1305 of Title 21 of the Code of
Federal Regulations. I hereby ratify and confirm all that said attorney must lawfully do or cause to be done by
virtue hereof.
________________________________ (Signature of person granting power) Date: _____________
Steve Chucri, Chairman, Board of Supervisors
APPROVE AS TO FORM: ______________________________________, Attorney for County
ATTEST: __________________________________________________, Office of the Clerk of the Board
I, Jason Peters (name of attorney-in-fact), hereby affirm that I am the person named herein as attorney-in-fact
and that the signature affixed hereto is my signature.
__________________________ (Signature of attorney-in-fact)
Witnesses:
1. __________________________ (Signature of witness)
2. __________________________ (Signature of witness)
Signed and dated on __________________________ (current date).
Notice of Revocation – to be completed only when Power of Attorney is revoked
The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application
for registration of the above-named registrant under the Controlled Substances Act or the Controlled Substances Import
and Export Act. Written notice of this revocation has been given to the attorney-in-fact _________ this same day.
__________________________ (Signature of person revoking power)
Witnesses:
1. __________________________ (Signature of witness)
2. __________________________ (Signature of witness)
Signed and dated on __________________________ (current date).