HCO & HCP Spend Tracking Form

I certify that I did not have any payments, expenses, or other transfers of value where the primary reason for the payment or value transfer is in connection with TMC product* (whether cash or in-kind) made by me or other relevant sales professionals, made directly or indirectly to, for, or on behalf of any healthcare professionals or healthcare institutions during this reporting period.

*In general, if TMC product is discussed for over 50 percent of the total time spent discussing products with the HCP, then the ISA’s primary reason for the payment or value transfer is in connection with the TMC product.

Independent Sales Agency Name:*

Year:*

Quarter:*

Q1Q2Q3Q4

TERMS OF ACCEPTANCE AND SIGNATURE: I, the Independent Sales Agent submitting this form, warrant the truthfulness of the information provided in this form.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.