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Form Approved: OMB No. 0910-0291, Expires: 10/31/08 See OMB statement on reverse.
U.S. Department of Health and Human Services Food and Drug Administration
MEDWATCH
FORM FDA 3500A (10/05)
A. PATIENT INFORMATION
1. Patient Identifier 2. Age at Time of Event: or In confidence Date of Birth:
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01-339
(Rev.9-07/6)
SAVE A COPY
CLEAR SIDE
TEXAS SALES AND USE TAX RESALE CERTIFICATE
Name of purchaser, firm or agency as shown on permit Phone (Area code and number)
Address (Street & number, P.O. Box or Route number)
City, State, ZIP code
Texas Sales and Use Tax Permit Number (must contain 11 digits)
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Reporting Methods (continued)
If you file your report on paper, please use the Texas reporting form 53-105. Computer printouts and spreadsheets should not be submitted. All forms, a reporting instruction manual, and magnetic tape reporting specifications can be read or printed from our Web site at:
http://www.window.state.tx.us/up/forms.html
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