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9. Does the practice comply with the federal and state laws in every state in which it purchases, stores and dispenses pharmaceutical and controlled substances? o YES o NO If no, please explain: ________________________________________________________________
10. Has the practitioner or its employees ever been disciplined by state or DEA regulators? o YES o NO If yes, please explain: _______________________________________________________________________________________________________
11. Has the owner ever had a DEA registration suspended or revoked? o YES o NO If yes, provide details: ______________________________________________________________________________________________________
12. Has the clinic ever had its state license suspended or revoked, or received other disciplinary action? o YES o NO If yes, provide details: ______________________________________________________________________________________________________
13. What controlled substance do you intend to purchase, use at the clinic or dispense to your customers from your facility? Please specify product: o 2 o 2N o 3 o 3N o 4 o 5
I attest that the information provided in the above DEA Customer Questionnaire is true and accurate to the best of my knowledge. (Please print completed document and sign)
Print Name of Veterinary Practitioner/Licensee Signature of Veterinary Practitioner/Licensee INTERNAL USE ONLY