"" Product
Name &
Name/Address of Purchaser
Quantity Sold
and Date/Time of Purchase
(written in by pharmacy)
(written in by purchaser)
MUST BE VERIFIED BY THE PHARMACY: CHECK BOX
Signature of Purchaser
Purchaser must
have Photo ID or
other ID
Photo & Name
in Section “B”
matches ID
Date
and
Time
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Under 18 U.S.C. §1001, an individual making a materially false, fictitious, or fraudulent statement or representation or for using a false writing or document that the
individual knows contains materially false, fictitious, or fraudulent information is subject to a maximum penalty of a fine and/or up to five years imprisonment.
13-d