Record Cease and Desist Letter to Pharmacists
After you have posted letters, use this form to record who you have contacted. It will then be displayed on a map showing the progress of the C&D campaign.

Once you've submitted this form, you'll have the opportunity to fill out a new form for other letters that you have sent. Just repeat for as many letters you have sent.

Please only use public available information (do not report any private address please).

Please don't add your own private name or your own private address, only add the publicly available name and address of the person(s) you sent the letter too. It doesn't matter who sent it, just who received it.

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Pharmacists First and Last Name(s)
Add multiple Pharmacists names if sending to the same location. Create a new line by hitting the enter key for the additional names.
Additional Names....
Add more names here if you've run out of space above.
Business Name or Professional Name of Pharmacists/Pharmacy *
eg. Maroubra Medical Centre, Dutton Park Police Station, Daniel Andrews premier of Victoria, The Hon. (Brad) Bradley Ronald HAZZARD, BA, DipEd, LLB(NSW), LLM(Syd) MP
Street Address of Pharmacy *
eg. 12 Harper Street
Suburb of Pharmacy *
State of Pharmacy *
Country of Pharmacy *
Contact Method *
Comments
Enter email, tracking numbers or fax number if applicable and any other comments.
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