Approval SAPUI5 Applications for Purchase Order and Purchase Requisition
Pseudofed Purchase
2
6501 E. Greenway Scottsdale, AZ 85254 Product Pack Size PSE Content Max # of Packs Quantity Purchased Advil Cold & Sinus 16 480 mg 3 Aleve Sinus Headache 10 1.2 g 3 Aleve-D Sinus & Cold 10 1.2 g 3 Allerfrim 24 1.44 g 2 Bromaline 120 ml 360 mg 3 Bronkaid 60 1.5 g 2 Children’s Motrin Cold 120 ml 360 mg 3 Children’s Sudafed Liquid 120 ml 360 mg 3 Claritin-D 12 10 1.2 g 3 Claritin-D 12 20 2.4 g 1 Claritin-D 24 10 2.4 g 1 Claritin-D 24 15 3.6 g 1 Drixoral 20 2.4 g 1 Kid Kare Liquid 120 ml 360 mg 3 Mucinex-D 18 1.08 g 3 Primatine Tabs 60 750 mg 3 Pseudoephedrine Liquid 120 ml 720 mg 3 Safeway Allergy and Congestion 10 2.4 g 1 Safeway Nasal Congestion 24 720 mg 3 Sudafed 24 720 mg 3 Sudafed 12 hour 10 1.2 g 3 Tylenol Cold 24 720 mg 3 Zyrtec-D 12 1.44 g 2 Zyrtec-D 24 2.88 g 1 Other By signing below, I agree that I am at least 18 years old and have not purchased more than the legal maximum amount of pseudoephedrine products in the past 30 days. Date Signature Time am pm Warning: Section 1001 of Title 18, US Code, state that whoever, with respect to the logbook, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious, or fraudulent statement of representation, or makes use of any false writing or document knowing the Pseudoephedrine Purchase Log Sheet Sales are limited to no more than 3.6 grams per day, and no more than 9 grams within a 30-day period. Must be 18 years old or older to Place ID here for photocopy
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Transcript of Pseudofed Purchase
6501 E. GreenwayScottsdale, AZ 85254
Product Pack Size PSE Content Max # of Packs Quantity Purchased
Advil Cold & Sinus 16 480 mg 3Aleve Sinus Headache 10 1.2 g 3Aleve-D Sinus & Cold 10 1.2 g 3Allerfrim 24 1.44 g 2Bromaline 120 ml 360 mg 3Bronkaid 60 1.5 g 2Children’s Motrin Cold 120 ml 360 mg 3Children’s Sudafed Liquid 120 ml 360 mg 3Claritin-D 12 10 1.2 g 3Claritin-D 12 20 2.4 g 1Claritin-D 24 10 2.4 g 1Claritin-D 24 15 3.6 g 1Drixoral 20 2.4 g 1Kid Kare Liquid 120 ml 360 mg 3Mucinex-D 18 1.08 g 3Primatine Tabs 60 750 mg 3Pseudoephedrine Liquid 120 ml 720 mg 3Safeway Allergy and Congestion 10 2.4 g 1Safeway Nasal Congestion 24 720 mg 3Sudafed 24 720 mg 3Sudafed 12 hour 10 1.2 g 3Tylenol Cold 24 720 mg 3Zyrtec-D 12 1.44 g 2Zyrtec-D 24 2.88 g 1Other
By signing below, I agree that I am at least 18 years old andhave not purchased more than the legal maximum amount of pseudoephedrine products in the past 30 days.
Date Signature
Time
am pm
Warning: Section 1001 of Title 18, US Code, state that whoever, with respect to the logbook, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious, or fraudulent statement of representation, or makes use of any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entity, shall be fined not more than $250,000 if an individual or $500,000 if an organization, imprisoned not more than 5 years, or both.
This form completed by an authorizedSafeway Pharmacy agent (check one):
RPh CPhT
ID Date of Birth Check:
Date Checked
Initials:
This form to be filed with the Pseudoephedrine Logbook according to Section 1001 of Title 18, US Code.
PseudoephedrinePurchase Log Sheet
Sales are limited to no more than 3.6 grams per day, and no more than 9 grams within a 30-day period. Must be 18 years old or older to purchase.
Place ID here for photocopy
