PPI, Inc.
310 Ed Wright Ln Ste E
Newport News, VA 23606
Fax +1-757-941-7142

 

DEA Required Ephedrine Identification Requirements Form

Regulations regarding Ephedrine-containing products are changing daily. In order that no delays occur on future orders, we are requesting that you complete this form. We believe this information will satisfy all your future requirements. We DO NOT  Ship  Vasopro Ephedrine To: Arkansas, Arizona, Hawaii, Iowa, Kansas, Minnesota, Illinois, Nebraska, New Mexico, Ohio, Oklahoma, Oregon, Washington State
INSTRUCTIONS: First print this form, then fill in your information and attach your identification. The form must be completed in its entirety. Any missing information will not process your order.
Please Fax this form to us at +1-757-941-7142
or Return by Mail to PPI, Inc., 310 Ed Wright Ln Ste E, Newport News, VA 23606
or scan and Email to sales@pricespower.com
Name: _______________________________________________________________________________________
Current Address: _______________________________________________________________________________
City: ______________________________________________ State: _____________________ Zip: ____________
Date of Birth: _________ /_________ / _________
Phone Number: ___________________________________________________________
(Phone number must be listed to current address. No business phone numbers.)
Is the phone number listed in your name? Please circle:        Yes          No
If NO, whose name is it listed in, and what relation are they to you: ______________________________________
Signature: _____________________________________________        Date: _________ /_________ / _________
                    Signature is mandatory

Driver's License Number: ___________________________________________________


Please attach a copy of your
DRIVER’S LICENSE or STATE ID CARD HERE

Address of Driver’s License/State ID Card
must match current address
No Exceptions
By completing this form you are acknowledging that the information you supplied is correct