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R OR HOSPITIAL OR FACILITY SECURITY FEATURES MAY BE PRINTED ON FRONT OR BACK OF RX PAD PRESCRIBER INFORMATION BACKGROUND INK DEA # ____________ NAME: _________________________________________________ ADDRESS: ________________________________ DATE: ________ SIGNATURE 6 CATEGORY OF LICENSURE 7 ________________________________ CATEGORY OF LICENSURE 8 SECURITY FEATURES HERE: - Resist erasures and reproductions - The blank must be printed on artificial watermarked paper - Contain blue or .

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How to fill out and sign Blank rx pad online?

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