Office of the Vermont Attorney General

TJ Donovan, Vermont Attorney General

2021 Samples Form

Vermont Office of Attorney General
109 State Street
Montpelier, VT 05609-1001

2021 Samples Disclosure Form for Manufacturers of Prescribed Products
Reporting Period for Pharmaceuticals, Biologics and Medical Devices
January 1, 2021 to December 31, 2021; Due Date: April 1, 2022

Name of Manufacturer *

Last Name of Recipient *

First Name

License Number/ID Number of Recipient *

NPI Number

Date Delivered *

Contents (Check all that apply) *

Product

Vouchers

Other

Product

Product Type

Product Name

Number of Samples

Units/Samples

Dosage

Description

NDC Number

Product Type

Product Name

Number of Samples

Units/Samples

Dosage

Description

NDC Number

Product Type

Product Name

Number of Samples

Units/Samples

Dosage

Description

NDC Number

Voucher

Voucher Product Type

Voucher Product Name

Number of Vouchers

Units/Vouchers

Description

NDC Number

Voucher Product Type

Voucher Product Name

Number of Vouchers

Units/Vouchers

Description

NDC Number

Voucher Product Type

Voucher Product Name

Number of Vouchers

Units/Vouchers

Description

NDC Number

Other

Other Product Type

Other Product Name

Number of Others

Other Sample Type

Description

NDC Number

Other Product Type

Other Product Name

Number of Others

Other Sample Type

Description

NDC Number

Other Product Type

Other Product Name

Number of Others

Other Sample Type

Description

NDC Number

109 State St
Montpelier, VT 05609

(802) 828-3171

Vermont’s lobbyist registration and disclosure law applies to certain communications with and activities directed at the Attorney General. Prior to any interactions with the Office of the Vermont Attorney General, you are advised to review Title 2, Sections 261-268 of the Vermont Statutes Annotated, as well as the Vermont Secretary of State’s most recent guide to compliance, available at https://www.sec.state.vt.us/elections/lobbying.aspx.