FaxNet

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RX FAX ALERT - FAX NET 1 - NETWORK of CRIME PREVENTION
IF YOU ARE UNABLE TO SUBMIT ELECTRONICALLY FAX THIS FORM TO: (602) 771-2748
PROBLEMS WITH TRANSMISSION? CALL PEGGY @ (602) 534-8562

Please fill in all appropriate fields below and click "Submit" when you are done.

Reporting Party
Date / Time
Pharmacy or Doctor Name
Individual Filing Report

Type of Incident (check all that apply)
		Forged Rx	Phony Telephone Rx	Dr. Shopper
		Rx Pad Theft	Armed Robbery	Other

Suspect
Suspect / Patient Name
Address
City
State
Zip
DOB
SSN
Sex		Male
		Female
Height	feet
	inches
Weight	lbs.
Ethnicity
Hair Color
Hair Length
Glasses		Yes
		No
Eye Color
Clothing

Vehicle Info
Make / Model
Color
License Plate
State

Summary (1500 char limit)

Email
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License Renewal Form
(for individuals) (PDF)

Permit Renewal Form
(for facilites) (PDF)

July 15, 2010
Board Meeting Minutes
(PDF)
(Draft Minutes Require Board Approval at Next Scheduled Meeting)