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					OBSTETRICS & PERIO THERAPY STUDY


 Receipt of Subject Payment Gift Certificates/Cards

This form must be completed upon receipt of monthly gift certificates/cards used for subject payments. When
completed, please fax the form to the OPT Study Administrative Center at 612-626-3938.




Date of Receipt:                  -         -
                         Month        Day       Year




Clinical Unit:




Total number of Certificates/Cheques Received:




 Number of Certificates Received for:

                                      Walmart:

                                       Target:

                                  Cub Foods:

                         Children’s Place:

                        Pathmark Grocery:

                        American Express:


    Upon receipt of the gift certificates/cards from the OPT Study Administrative Center, this clinical site accepts
    full responsibility for the proper handling, security and distribution of the certificates/cards and acknowledges
    financial responsibility for any loss or theft of these items.



 Name of Person Completing Form (Print):



 Signature of Person Completing Form:



  Once this form is completed, FAX a copy immediately to the Administrative Center at 612-626-3938.




OPT Form 101       V1     (1-1)       MAR 03

				
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