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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. (Note that Ephedrine products can not be shipped to the state of California.)
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 (877) 838-0560
or Return by Mail to D&E Pharmaceuticals, Inc., 206 Macopin Rd, Bloomingdale, NJ 07403
or scan and Email to customerservice@dnepharm.com
Name: _______________________________________________________________________________________
Current Address: _______________________________________________________________________________
(Address must match driver's license address - No exceptions)
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: ___________________________________________________

One form of identification must be selected from BOTH Class 1 and Class 2
AND a copy must be attached here where indicated.

 
Class 1  

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


Class 2

Please attach copy of your PERSONAL ID HERE
(other than what you used for Class 1)

For example: Vehicle Registration Card, Passport,
Social Security Card, Voter Registration Card,
or State Identification Card

By completing this form you are acknowledging that the information you supplied is correct.