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Form 106 2000
ZIP Code)
2. Phone No. (Include Area Code)
ZIP CODE
3. DEA Registration Number
4. Date of Theft or Loss
2 ltr. prefix
5. Principal Business of Registrant (Check one)
1
2
3
4
7 digit suffix
6. County in which Registrant is
located
7. Was Theft reported
to Police?
Yes
9. Number of Thefts or Losses Registrant
has experienced in the past 24 months
8.
5
6
7
Pharmacy
Practitioner
Manufacturer
Hospital/Clinic
Distributor
Program
Other (Specify)
Name and Telephone Number of Police...
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