Iowa Board of Pharmacy

susan.wennekamp@iowa.gov

6200 Park Ave., Ste. 100 Des Moines, IA 50321

515-281-5944

Precursor Substances Transaction Report

Type of Transaction Reported

Recipient

Provider

Recipient Name

Phone Number

Email

Recipient Address

Address or Location

Provider Name

Provider Address

Address or Location

Name of Substance(s) Transferred/Sold

Name of Substance *

Quantity *

Name of Substance(s) Transferred/Sold

Name of Substance

Quantity

Name of Substance(s) Transferred/Sold

Name of Substance

Quantity

Name of Substance(s) Transferred/Sold

Name of Substance

Quantity

Name of Substance(s) Transferred/Sold

Name of Substance

Quantity

Name of Substance(s) Transferred/Sold

Name of Substance

Quantity

Business/Activity of Person or Business Reporting

Manufacture

Wholesale

Retail

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First Name

Last Name

Email

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.