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furnishes any precursor chemical or regulated chemical to (Arizona Department of Public Safety)

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PRECURSOR AND REGULATED CHEMICAL REPORT
Arizona Revised Statute 13-3404 requires: A manufacturer, wholesaler, retailer or other person who sells, transfers or otherwise
furnishes any precursor chemical or regulated chemical to a person in this state, not less than twenty-
one days before delivery of the
substance, shall submit a report of the transaction to the Arizona Department of Public Safety. A manufacturer, wholesaler,
retailer or
other person who receives from a source outside this state any pre
cursor chemical or regulated chemical shall submit a report of the
transaction to the Arizona Department of Public Safety (see exceptions under A.R.S. 13-
3404(E). Failure to report or to comply with
A.R.S. 13-3404.01 is a felony.
Part I: Provider
Person selling, transferring or furnishing the substance is: (check one)
Manufacturer
Wholesaler
Retailer
Other:
Full Name of Individual Completing Transaction
Street Address
City
State
Zip Code
AZ Board of Pharmacy Permit #
(Selling, transferring or furnishing without a permit is a felony)
Telephone
Social Security Number
Part II: Receiver
Person buying, acquiring or receiving the substance is: (check one)
Manufacturer
Wholesaler
Retailer
Other:
Full Name of Individual Completing Transaction
Telephone
Social Security Number
Home Address
City
State
Zip Code
Business Name
AZ Board of Pharmacy Permit #
(Selling, transferring or furnishing without a permit is a felony)
Business Address
City
State
Zip Code
Business Telephone
Date of Birth
Identification (Photo ID Required – List type & number)
Part III: Transaction Details
Chemical Designation (Check one)
NDC Number
Precursor Chemical I
Precursor Chemical II
Regulated Chemical
Substance Name
Quantity Sold, Transferred, or Furnished
Invoice Number
Transaction Method:
Amount
Cash/Money Order Check Credit Card Other
Date Ordered
Date to be Delivered
To the best of my knowledge, the information provided in this report pertaining t
o the sale, transfer or furnishing of precursor chemicals
or regulated chemicals, or the receipt of precursor chemicals or regulated chemicals, is true and accurate.
Print Full Name of Reporting Party
Date
Title
X
Signature
Mail To: ACTIC Watch Center E-Mail to: ACTIC@AZDPS.GOV
Arizona Department of Public Safety
Mail Drop 3900
PO Box 6638
Phoenix, AZ 85005-6638
White Copy: DPS Canary Copy: Retain for Records
DPS 802-07016 Revised 1-2014
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Completed 20 July 2020

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