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R Therapy Evaluation Program FOR NCI USE ONLY Return. No.: Return Drug List Return only agents supplied by: CTEP, DCTD, National Cancer Institute The agents listed below were ordered by (one investigator per form only): Dr. ONLY Signature of Authorizing Official: Date of Authorization: NSC Number Agent Name Check here if returned receipt should be mailed to the above address, OR fill in a fax number below Strength & Formulation NCI Protocol Number (Specify vials, capsules, or tablet.

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