2023 Samples Form

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

2023 Samples Disclosure Form for Manufacturers of Prescribed Products
Reporting Period for Pharmaceuticals, Biologics and Medical Devices
January 1, 2023 to December 31, 2023; Due Date: April 1, 2024

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

Re-order	Product Type	Product Name	Number of Samples	Units/Samples	Dosage	Description	NDC Number	Weight	Operations
	Product Type	Product Name	Number of Samples	Units/Samples	Dosage	Description	NDC Number	Item weight

more items

Voucher

Re-order	Voucher Product Type	Voucher Product Name	Number of Vouchers	Units/Vouchers	Description	NDC Number	Weight	Operations
	Voucher Product Type	Voucher Product Name	Number of Vouchers	Units/Vouchers	Description	NDC Number	Item weight

more items

Other

Re-order	Other Product Type	Other Product Name	Number of Others	Other Sample Type	Description	NDC Number	Weight	Operations
	Other Product Type	Other Product Name	Number of Others	Other Sample Type	Description	NDC Number	Item weight

more items

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