EFTA00521905.pdf

0 HENRY SCHEIN° Henry Schein. Inc • 135 Duryea Road • Melville. NY 11747 CERTIFICATION BY FOREIGN CUSTOMER Customer Name: Customer Number: Address: Ship to Address and Telephone Number: Country: If your country requires you to have a license to dispense or to order prescription drug or device products from Henry Schein, Inc. please complete this and INCLUDE A COPY OF YOUR LICENSE Country in which customer is licensed to order & possess prescription drugs and/or devices: License Number: Expiration Date: Name, Address, and Telephone Number of Licensing Authority: I certify that the information I have provided above is truthful and accurate, and that I intend to use the prescription products purchased from Henry Schein, Inc. in a manner consistent with the laws and regulations of the country in which I am licensed. I understand that Henry Schein, Inc. may contact the licensing authority identified above to confirm that I hold a valid license to order & possess the prescription products I purchase from Henry Schein, Inc. Signature Date Print Name If your country DOES NOT require you to have a license for the ordering of prescription drug or device products from Henry Schein, Inc. please sign below: I certify that my country of residence/practice does not require me to be licensed when ordering and possessing the prescription drug or device products sourced from Henry Schein, Inc. Signature Date Print Name * This form is valid for 3 years from signature date. Updated copies of customer's license are required to be attached if expiration date is shorter than 3 years. Rev. 4117/14 EFTA00521905