Get Epi-2016-0317 Certification Form: Free ... - Rxassist

Filling out the EPI-2016-0317 Certification Form is essential for schools to participate in the EpiPen4Schools Program. This guide provides clear step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the EPI-2016-0317 Certification Form online.

1. Press the ‘Get Form’ button to retrieve the EPI-2016-0317 Certification Form and open it in your preferred document editor.
2. Begin by entering the name of the School or School District at the designated section. This information identifies the entity seeking to obtain the free EpiPens.
3. Provide the School Address, including the City, State, and Zip Code. Ensure that the address matches the official records of your institution.
4. Fill in the School Phone number for contact purposes. This number should be directly associated with the administration.
5. Complete the Authorized School Signatory Name, Title, and Email fields. This identifies the individual responsible for signing the document.
6. Sign and date the form in the designated section to validate the certification. This signature confirms that all information provided is accurate.
7. Indicate the quantity of 2-Pak and/or Jr 2-Pak cartons you wish to order. Note that the total quantity must not exceed the limits established by the program.
8. If ordering for multiple schools, provide a list of all schools along with their addresses, ensuring accurate totals are recorded based on the number of schools listed.
9. Once all fields are completed and reviewed, save your changes, and prepare to submit the document through the specified method, such as faxing or emailing.

Complete your EPI-2016-0317 Certification Form online today to ensure your school has access to necessary emergency resources.