Class III - V Control Drug Report

If you'd prefer, you may also print a .pdf version of the form and fill it out. NOTE: Products can only be combined on the same line if the Drug, Exp. Date and Lot # are identical. Back to the Forms Page

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			Pharmaceutical Returns Service
			110 Oak Street
			North Aurora, IL 60542-9904
			RP0194174

# of Units Being Returned	# of Units in Original Package	Drug/Brand Name	Strength	NDC Number	Lot Number	Exp Date (MM/YY)	Drug Class 3     4     5
100	200	Sample Drug	5mg	99999 9999 99	5A5BCD555	12/06

NOTE: Please print and send a copy of this form with your class III-V drug shipment.