LIST ORDER FORM

OREGON BOARD OF PHARMACY 800 NE OREGON STREET, SUITE 150 PORTLAND OR 97232 TELEPHONE: (971) 673-0001 www.pharmacy.state.or.us

FOR BOARD USE ONLY

RECEIPT # BATCH DATE

[0324] $80.00

ENTERED BY

ALL FEES ARE NON-REFUNDABLE Name/Company: Address:

E-Mail: Return this letter PLUS THE ADDRESS OR E-MAIL ADDRESS YOU WISH YOUR ORDER TO BE SHIPPED TO. Check or Money Order must be received with your order. Please make your check or money order payable to the Oregon Board of Pharmacy. Each category is considered a separate list request and requires an additional payment. The charge for a list category is: $80.00 CD or E-mail

Lists will only include name, address and the Issue/Expiration dates of the licensee unless you specifically request not to have the Issue/Expiration dates. Telephone numbers of individuals or establishments are not available. Lists can be sorted by the categories listed below. Please check your choice. If you do not make a choice, lists will be sorted by last or business name. [ ] City [ ] Last or Business Name [ ] License Number [ ] Zip Code

Please check from the following list categories: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] All Pharmacists licensed with the Oregon Board of Pharmacy. (This category includes pharmacists residing in-state and out-of-state) Only those licensed Pharmacists with addresses IN Oregon. All Pharmacies licensed with the Oregon Board of Pharmacy (This category includes those pharmacies located in-state and out-of-state) All Pharmacies located IN Oregon All Pharmacy Techs [ ] [ ] All Pharmacy Interns All Certified Pharmacy Techs

Wholesalers (Prescription and Nonprescription Wholesalers) Manufacturers Other (i.e., County Health Clinics, Drug Rooms, Animal Euthanasia)

Lists will only be provided in Excel Format. If you should have any questions, please contact our office at (971) 673-0001.
ALL RETURNED CHECKS WILL BE ASSESSED A $35.00 RETURNED CHECK FEE PURSUANT TO ORS 30.701(5)
Revised January 12