Sample Receipt Forms Sample Clauses

Sample Receipt Forms. Each Impax PSR shall complete a Sample Receipt Form with respect to each Sample disbursed by such Impax PSR. In each instance where a Sample is disbursed, the Impax PSR providing such Sample shall ensure that the Neurologist receiving such Sample signs the applicable Sample Receipt Form in acknowledgment of receipt of such Sample. Each Impax PSR shall mail to Impax or Impax’s Permitted Subcontractor (as determined by Impax), in pre-addressed, postage-paid envelopes provided by Impax, or send via electronic means, on a regular basis no less frequently than quarterly the original completed Sample Receipt Forms for Sample disbursements performed by such Impax PSR during the period covered by the report. A copy of all such Sample Receipt Forms shall be kept by Impax or its Permitted Subcontractor. Impax shall ensure that each Impax PSR fills out the Sample Receipt Forms accurately, completely and timely. For the avoidance of doubt, the foregoing obligations are in addition to the procedures set forth in Article 10.

Sample Receipt Forms. Sample Receipt Forms utilized by Impax for distribution of Samples under this Agreement shall contain the following information: • Sample Receipt Number • PSR ID Number • PSR Name • Sales Territory Number • Call Date • Prescriber Information • Name [Last, First, Middle Initial] • Address • Professional Designation [MD, DO, NP, PA, Other (specify)] • State License Number • Product Information • Product Name [e.g., XXXXX] • Dosage Strength/Package Size [e.g., 50mg (1 x 7)] • NDC Number [e.g., 1211-40] • Manufacturing Lot Number • Quantity distributed • Practioner Signature • PSR Signature • The following disclosure language immediately under the Practioner Signature: • “By signing, I certify: I am a licensed practitioner and can legally prescribe in my state; if my authority is dependent, I have a current collaborative agreement that includes the samples requested. I am requesting samples so I may evaluate the efficacy & tolerability in an appropriate patient. These samples will not be traded, sold, offered for sale, bartered, or returned for credit, nor be submitted to any public or private third-party payor for reimbursement. This is my personal signature.” Initial Training - XXXXX. POA Training - XXXXX. New Hire Training - XXXXX. þ Total Prescriptions in XXXXX Category (All Prescribers) XXXXX XXXXX XXXXX TRx — All Prescribers XXXXX XXXXX XXXXX Market Share — All Prescribers XXXXX% XXXXX% XXXXX% Total Prescriptions in XXXXX Category By Target Neurologists XXXXX XXXXX XXXXX TRx — Target Neurologists XXXXX XXXXX XXXXX Market Share — Target Neurologists XXXXX% XXXXX% XXXXX% Incremental Market Share (amount by which increase in Target Neurologist Market Share for XXXXX exceeds increase in Market Share for XXXXX for all prescribers) XXXXX% Incremental Prescriptions by Target Neurologists above Baseline (Incremental Market Share times Total Prescriptions in XXXXX Category By Target Neurologists) XXXXX Average Selling Price per Tablet for XXXXX tablets $XXXXX XXXXX tablets per TRx XXXXX Value of each XXXXX TRx $XXXXX Incremental Net Sales (Net Sales resulting from Target Neurologist TRxs above baseline) $XXXXX Incentive Fee: 15% of Incremental Net Sales $XXXXX Market Share for XXXXX for all prescribers is calculated for Contract Year 1 and Contract Year 2 as shown above. Market Share for all prescribers increased XXXXX% from year 1 to year 2 (XXXXX% - XXXXX%). The same calculation is done for the Target Neurologist Market Share. This calculation shows market shar...

Sample Receipt Forms. Sample Receipt Forms utilized by Impax for distribution of Samples under this Agreement shall contain the following information: