Retail Pharmacy Controlled Substance Questionnaire

I, as the Owner, Authorized Representative or Officer of the Owner, declare under penalty of perjury that I have completed this Retail Pharmacy Questionnaire to the best of my knowledge and believe the information provided is true, accurate and complete.

**NOTE: Prior to adding any new personnel authorized to order Controlled Substances, you are required to notify Real Value Products and provide the information below.

By signing this document, the undersigned customer (“Customer”) affirms that the below statements are true:

- Customer is aware of and will abide by all state, federal, and other applicable regulatory standards regarding the purchasing, storage, handling, dispensing, sale, recordkeeping, and reporting of controlled substances.

- Customer has effective controls in place to guard against dispensing controlled substances if there is reason to suspect a prescription is not issued for a legitimate medical purpose, or in the course of normal professional practice.

- Customer has effective controls in place to guard against theft and diversion of controlled substances into other than legitimate channels.

- Customer maintains licenses in good standing with all state, federal, and other applicable regulatory agencies with which they are registered to handle controlled substances. Customer understands that any changes in license status must be immediately reported to Real Value Products Corporation.

- Customer maintains and adheres to written policies and procedures to ensure compliance with all of the above.

In addition, Customer understands that Real Value Products Corporation is required by DEA regulations, as well as state and federal law to report suspicious orders, and agrees to act in good faith assisting Real Value Products Corporation by supplying information that may be requested in order to properly evaluate orders we may identify as being of unusual size, frequency, or deviating from a normal order pattern. Customer understands that information supplied to Real Value Products Corporation is retained in their customer file, which may be provided upon request to any government regulatory agency as allowed by applicable laws/regulations.

Failure to comply with this agreement may result in Real Value Products Corporation being unable to supply Customer with controlled substances.