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Attachment F:
<br />AnlfriraJ With drawaJ F orm
<br />Date o flre quest:
<br />fo cm l11J1 tructi:an .:
<br />1-. DO Em ~n-c-,• F~e i:-:a re d n :.n711d Ru n10.IEP ] .p, u..ll:1. le to .,ecc i~c ""'I es t.I fo1 11~1ivlt al
<br />mc d~aNnsir-,..;r, 1=1 hn llh Ju ru.:l ldb".
<br />~-To ord en.nf •1r.ils , ;o r•~uestin.; LH! • rn f ly nu s ·to~m pl c~ t lr-fcrm. P na e:i mi:J •t• SOI! the fo rm
<br />.id ,e;m. 1 ll to tusica.b.a;;,;n@:dah .w,uov :and Qurtes copy dahe=Ul@doh r.a.;o • u sto.; ~o.nth• nJ
<br />"ith d ~.iv@ m t h e s u b-j<e ct On e .
<br />3 . UOH Emc rgc n-:y Pr~p a,c:!n-u• and Re sponse l EP ) w1U i::=-nfln ate rc 1 u uts ,Yii h t c W:u h, ;tQn :int:
<br />Ph:mn;o:y Assoc:iaf::n to ve rify• pplf <:;h :rin :r.1Mty . The n, cn::11 ihc r:qu e ,t has bo_u, ,Ffro\l e d by
<br />OOH lc .rd c rih ip~ DO !i EP R s t ~ ,ID work to lcc~tt' the q ue,tcd mi,dbti:i n, in c itherth e cu rt ent
<br />~_u p p,lych ain o r ,t.xk fro m th e_ oo k a ~h,c.
<br />J . lf m c d t fa os arc ;r,·ai J;,b lc, .D O 6'11: :rt.i lh-1111 wn tr.t t h e r-e.qu :,tin;l:r-al h e alth j rbdlctia-n t;:i
<br />a.nfifll" rntpi;io , lou l:bn ~d pol~t o lc,:,n r,;-t.
<br />5 . .OO H El'R wiJl a u i;n a C'IU~me , n~ .;)<d e r n uml:ce to th: r:qu euin .; k:-.a l h.,,.ilt J risdic1~:n. :irnota l c
<br />tile n uri'tl:e r o n p~e M,, .i d san/cmllil 1ttthe JF-p ro~e d q11an1,t ofan,-lr.i1s ~t h i: re c;uc .n ir ;~I
<br />ce-alth ju 1is_di:ti::11 . Estitnmd t im,, <>hntin.l dapv t.:h 11p0n the uq;c nC)"Of t h e ,it1,:11 i~n, t ime re c e ived.
<br />an ~ ;ec;;rp Fhr-l~n.
<br />6, Th e ,e q u u fin ; ~,I hnlth jl!ril:d.:tj~11 ill •~n an d d ate IO r..k/1 v,le d;;e rc.a:lpl <>f an ti-.•iralJ upo:n
<br />de ll very .
<br />7 . Th e reque t in11 ~:;I hc!a lth jo risd i:ti:,n v,il l =-;,u to t1m,r1t llf<e =tock ro DOH fPR wli~in 60 dOY;, Wltl!
<br />a n cxpir.im -n d ate of at le ac t tlm :i: y ear> ov t usm i; th e n tivinil Aet11 rn f<i nn h>a;i! 3 ),
<br />a. DOH fPR wm re t:>iff the ~mp~tul iln tivi,r.l VI, h dram! fo rm fo r 7 ar,.
<br />1Rnque-stln& load ~aaltll )tmclidion :
<br />Otgen-intion p,111 Ut e loo! hnlth jumdiction i> reqm:>tirt1 the mecrlClltlonsfor :
<br />Contact: Title:
<br />!'hone lr: E-Mai l:
<br />R'equutedAntivir;i(s fr ncluil-e typc,WH! and qucanfity): Sh i p'pm 11Aild reu;
<br />(&: T11mif{u, 75mg , !Opad:s ~ j/Jpil.ls)
<br />57
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