Enter a unique one-up record number for each transaction.
Record
Number |
Enter "S" for Sales or "R" for Returns.
Trans.
Type |
Enter your company's DEA Registration Number.
DEA
Registration
Number |
Enter your company's unique identification number for this product or the NDC number for this product.
Product
ID |
Enter the trade name of the product (e.g., Actifed Cold and Allergy Tablets ®, Sudafed Severe Cold Caplets ®).
Product Name |
Enter "8113" for drug products that contain EPHEDRINE, "8112" for drug products that contain PSEUDOEPHEDRINE, and "1225" for drug prodcuts that contain PHENYLPROPANOLAMINE.
Chemical
Code |
Enter the type (e.g., tablet, liquid, caplet) of dosage form.
Dosage
Form |
Enter the dosage strength in milligrams (e.g., a 60 mg tablet should be entered as "60". A 15mg/5ml liquid dose should be entered as "3").
Dosage
Strength |
Enter the product amount in the package (e.g., if a bottle contains 100 tablets enter "100". If a bottle contains 4 fl. oz. enter "118.294").
Package
Size |
Enter the number of packages purchased by the customer.
No. of
Pkgs. |
Enter the lot number of the products sold to the customer.
Lot
Number |
Enter only the first name of the purchaser.
First
Name |
Enter only the last name of the purchaser.
Last
Name |
Enter the street number and street name of the purchaser.
Address 1 |
Enter additional address information of the purchaser (e.g., apt#, P.O. Box, etc.) If this information was not provided, please leave this field blank.
Address 2 |
Enter the city name of the purchaser.
City |
Enter the state code of the purchaser.
State
Code |
Enter the Zip Code of the purchaser. Do not enter a hyphen for 9 digit Zip Codes.
Zip
Code |
Enter only the first name to whom the product was shipped if different than the first name of the purchaser.
First
Name |
Enter only the last name to whom the product was shipped if different than the last name of the purchaser.
Last
Name |
Enter the street number and street name to where the product was shipped if different than the Address 1 of the purchaser.
Address 1 |
Enter additional address information to where the product was shipped (e.g., apt#, P.O. Box, etc.) if different than the Address 1 of the purchaser. If this information was not provided, please leave this field blank.
Address 2 |
Enter the city name to where the product was shipped if different than the city of the purchaser.
City |
Enter the state code to where the product was shipped if different than the state code of the purchaser.
State
Code |
Enter the Zip Code to where the product was shipped if different than the Zip Code of the purchaser. Do not enter a hyphen for 9 digit Zip Codes.
Zip
Code |
Enter the Date the product was shipped from your company. Please Use the "MM/DD/YY" format.
Date of
Shipment |