Petition Completion Form – United Pharmacy Coalition

Petition Completion Form & Signature

By completing this form, you agree that you have not previously completed any form of this petition, in an effort to impress the Federal Trade Commission to act swiftly on behalf of yourself, your community, and your access to proper healthcare as you see most fit.

Please complete all fields of this form to complete the petition. Any incomplete section invalidates submission of your signature to the petition.

First & Last Name

Preferred Email

Choose the Title that Best Describes You

Other Description

Your Business/Residence Address

Your Business/Residence City & State

Digital Signature Use Agreement

By checking this box, I agree to affix my digital signature with the full force available as my written signature to this petition. I agree with every aspect of this petition and request my name be added to a digital copy of this petition upon my behalf. By checking this box, I agree that all information included here is complete and accurate to the best of my abilities, and that I am a legal citizen of the United States of America, able to legally sign this petition.