Sale of Controlled Substances to Vessels
(Name of registrant) _______________________________
(Address of registrant) _______________________________
(DEA registration number) _______________________________
Line No. | Number of packages ordered | Size of packages | Name of product | Packages distributed | Date distributed |
1 | |||||
2 | |||||
3 |
FOOTNOTE: Line numbers may be continued according to needs of the vendor.
Number of lines completed _______________________________
Name of vessel _______________________________
Vessel's official number _______________________________
Vessel's country of registry _______________________________
Owner or operator of the vessel _______________________________
Name and title of vessel's officer who presented the requisition _____________
Signature of vessel's officer who presented the requisition ______________
21 C.F.R. §1301.25