First Nation Group’s Pharmaceuticals Division Return Form

We value our customers and their needs. Please complete the following First Nation Group’s Pharmaceuticals Division Return Authorization Form, and a First Nation Group representative will follow-up with you directly.

*All returns can be subject to a restocking fee.

*By filling out and submitting this return form, you are verifying that all returned merchandise has been kept under proper conditions for storage, handling, and shipping as required by applicable state and Federal requirements.

Returns - Pharmaceuticals Division

Vendor/Facility *Please include city and state

Contact Name *

First

Last *

Last

Contact Phone Number

Extension

Contact Email Address *

Purchase Order Number (PO) *

Date of Invoice (MM/DD/YYYY) *

*Invoices older than 90-days will be reviewed for approval

NDC and Quantity Returning *

*If all product included on the PO is being returned, please enter “ALL” in the field provided above

Serial/Lot Number(s) *

*If returning only a portion of the product listed on the PO, please indicate ALL serial/lot numbers associated with returns

Reasons for Return *

Any additional applicable notes?

Name of Contact Completing Return Form

First

Last

Ongoing Assurance

Please check here to verify all returned merchandise has been kept under proper conditions for storage, handling, and shipping as required by applicable state and Federal requirements. After processing the return, a return authorization form will be sent to obtain a physical signature attesting to this. *Must be signed by a financially responsible person at the practice or by his/her delegate where written documentation of delegation exists.

If you are human, leave this field blank.