DEA - Unlawful Pharmaceutical Drug Sales on the Internet: Reporting Form

Please submit as much information as possible about the website you are reporting.

Website Internet Address (URL) [Required]

Date Visited

Month: Day: Year:

Please provide any contact information available from the website (e.g. address, phone, email). Limit: 500 characters.

Describe the reason you are reporting this website [Required Limit: 2000 characters]

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Last Name

First Name

Street Address

Address (Continue)





Daytime Phone Number

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Fax Number

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Email Address

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