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EXEMPTION AUTHORIZES APPLICANT TO HANDLE THE CONTROLLED SUBSTANCES AT EXEMPT LOCATION ONLY. THIS FORM MUST ACCOMPANY APPLICATION FORM IN WHICH YOU ARE CLAIMING EXEMPTION. APPLICANT INFORMATION AS LISTED ON FORM NAR-77 NAR-77A NAR-77B NAR-78 NAR-78A OR NAR-78B Applicant or Provider s Representative Name Email Address Current CSR Number IF Any Current Board License Number Expiration Date Current Federal DEA Registration Number Current National Prov.

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