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Get Application Form Of Actavis

Drug(s) and/or device(s) requested by my licensed prescriber on the prescription attached to this application and that all information provided in sections 2.0, 2.1 and 2.3 is correct and complete. I understand that Actavis Pharmaceuticals, Inc. Patient Assistance Program ( Program ) is entitled at any time to request verification of any such information which I agree to provide from me, my employer, and/or my insurer. I understand that the program may contact me for verification of my appl.

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