Sample Request Form Thank you for your interest in obtaining FSC Pediatrics samples! To receive samples, please complete this form, sign and date it and fax it to 407-641-9776 or email to [email protected] Medical Practice Name Address City State Phone Fax Zip/Postal Code Product NDC# Size Quantity Besivance® (besifloxacin ophthalmic suspension) 0.6% 24208-446-02 2mL  1  2  3  4 Bepreve® (bepotastine besilate ophthalmic solution) 1.5% 24208-629-10 1 mL   2  3  4 Primsol® Solution (trimethoprim hydrochloride 50 mg / 5 mL) 13551-501-01 20mL  1  2  3  4 1 *Please allow 10 days for delivery. “By signing this form I certify that I have requested the items listed above in the quantities designated. I further certify that I am a licensed practitioner eligible to receive and prescribe these samples. If I am a Nurse Practitioner or Physician Assistant, I certify that I am authorized and eligible in the state within which I am currently practicing, to request and receive these samples and that I have my supervising Physician’s approval to do so. My signature on this form certifies that I recognize that sample products are for the medical needs of my patients and will not be sold, traded, bartered, returned for credit or utilized to seek or obtain reimbursement.” MD DO NP PA Other (Please Specify)  Professional Designation NPI #  License Number State of Licensure Practitioner’s E-mail Address Authorizing Practitioner Name (Print) Specialty Authorizing Practitioner Signature (NO Stamps) Date You can find product information at www.fscpediatrics.com. If you have any questions regarding the FSC Pediatrics product sampling program, please contact FSC at (704) 941-2500. FSC Representative Name Territory Number BESIVANCE & BEPREVE are manufactured and distributed by Bausch & Lomb Inc., 8500 Hidden River Parkway, Tampa, FL 33637 (Florida Manufacturer permit # 20:00038), and marketed by: FSC Pediatrics, Inc. 6000 Fairview Road, Suite 600, Charlotte, NC 28210. Primsol® Solution is manufactured for and distributed by: FSC Laboratories, Inc. 6000 Fairview Road, Suite 600, Charlotte, NC 28210 BESIVANCE & BEPREVE are registered trademarks of Bausch & Lomb Incorporated or its affiliates. All other product/brand names are trademarks of their respective owners. US/BEP/12/0021d(1)b 2014 FSC Laboratories, Inc. 050814001 Rev 0 May 2014 US/BEP/12/0021d(1)b