SAMPLE REQUEST FAX FORM To receive your complimentary samples of Androderm® (testosterone transdermal system) CIII 4 mg patch, complete this form and fax it, along with a copy of your DEA license, to: Androderm® Sample Order Fulfillment Fax #: 1-877-619-5796 Your shipment of professional samples may only be sent to your office address as listed on your DEA license. Please note: In compliance with the Prescription Drug Marketing Act regulations, incomplete request forms cannot be processed and samples will not be forwarded. Practitioner Name Professional Designation MD DO PA NP (Circle) Phone Number Fax Number Email Address (No PO boxes) City State Zip (Samples will not be issued or delivered to a PO box; please provide your office street address.) Product Request (please check one) ❑ ❑ ❑ Product Description 2 cartons 2 cartons x 4 patches x 4 mg CIII 4 cartons 4 cartons x 4 patches x 4 mg CIII 8 cartons 8 cartons x 4 patches x 4 mg CIII Note: These controlled substance products are subject to the requirements of the Drug Enforcement Administration (CFR Part 1300 to END). NDC 52544-077-99 Manufacturer: Watson Laboratories, Inc. Authorized Sample Distributor: Anda Inc. By signing this form I request the drug samples listed herein and certify that my DEA number is valid, and I am a licensed practitioner currently authorized under applicable federal and state law to request, receive, prescribe, and dispense these drug samples. I certify that I have requested these samples for the legitimate medical needs of my patients. I understand that the sale or offer to sell a drug sample is a federal offense. I certify that I will not seek payment from any patient or third-party payor for these drug samples and I will not sell, resell, trade, barter, return for credit, or seek reimbursement for any drug sample. Practitioner/Physician Signature Date (Authorized Practitioner Signature) State License Number Exp. Date DEA License Number Exp. Date Any recipient of this fax may request that Actavis not send any future advertisements to this or other specified telephone facsimile machines. To make such a request, please call 1-866-406-2911 or 1-954-217-4500 x. 74533 or fax the request to 1-954-217-4395. Your request must identify the telephone number of each facsimile machine to which the request relates. Your request will no longer be valid if, after your request is made, you provide express invitation or consent to Actavis to send advertisements to you at the identified facsimile numbers. Any failure to honor your request within 30 days is unlawful. Check here ❑ I agree that the information I am providing may be used by Actavis, its affiliates or vendors to keep me informed about new products, services, special offers, or other opportunities that may be of interest to me, as they become available. Actavis will take appropriate measures to protect my information. I can stop Actavis from sending me future communications by sending a brief note with my name and address to Actavis at Morris Corporate Center III, 400 Interpace Parkway, Parsippany, New Jersey 07054, or by clicking on the “unsubscribe” link which will be available in future email communications. To be filled out by Actavis representative: Representative Name Territory Number Androderm® and its design are registered trademarks of Watson Laboratories, Inc. © 2014, Actavis Pharma, Inc., Parsippany, NJ 07054. All rights reserved. 11069 7/14 ANDA