SAMPLE LIQUIDATION FORM

NAME: __________________________ ___________________ TERRITORY: ______________________ TOTAL CALL TARGET ACTUAL CALLS FOR THE MONTH OF: DATE SUBMITTED: % CALL RATE

TYPE OF SAMPLES / PROMO MATS ISSUED ! " # $ % & ' ( )

QTY OF SAMPLES / PROMO MATS ISSUED TO TM

LESS QTY ISSUED TO DOCTORS

TOTAL RETURNS (SAMPLES /PROMATS)

CARRY-OVER
FOR PROVINCIAL US

SUBMITTED BY: ASST. ____________________________ _____________________________

VERIFIED BY: ABUM __________________________

RECEIVED BY: SALES & ADMIN

TERRITORY MANAGER SIGNATURE

PRINTED NAME OVER SIGNATURE

PRINTED NAME OVER