Physician Recipients Sample Clauses

Physician Recipients. Prior to each delivery of Sample Product by ICS to a Physician Recipient, the Company will provide ICS with a completed sample request form in a form mutually agreed upon by the Parties, which must be signed by the physician making the request (the “Sample Request Form”). The Sample Request Form will contain the following information: 4.1.1 The applicable state license or authorization number (or DEA number where a controlled substance is requested) for the physician authorized to receive Samples Products; 4.1.2 The name, address, professional title and signature of the physician making the request; 4.1.3 The proprietary or established name and strength of the Sample Product requested; 4.1.4 The amount of Sample Product requested; 4.1.5 The date of the request; 4.1.6 The full names of the Company and ICS; and 4.1.7 Any other information required by § 203.30 or other applicable law for the distribution of Sample Products to a physician.