RedSail Conference Standalone Promotional Form

Thank you for your interest in RedSail's DSCSA compliance offering. By enrolling in the DSCSA Compliance Solution ("the "Service") you authorize RedSail Technologies ("RedSail") to share your information with its third party DSCSA compliance solutions vendor to continue the enrollment process. Service Description: Access to a cloud-based solution which covers all aspects of being compliant with the current and upcoming DSCSA mandates.

Enrollment and Pricing Information Monthly Fees: Web Portal Access $50 per month per location. This fee is subject to change upon prior written notice from RedSail.

Pharmacy Store Name ("Pharmacy")*

Primary Contact Name (print)*

System ID (NRx and PrimeCare only)

Primary Contact Phone Number*

Format: (000) 000-0000.

NPI Number*

Email Address*

example@example.com

By signing below, I agree to pay for the Service listed above. Once enrolled, the Pharmacy will receive information on continuing enrollment and it is responsible for completing enrollment of Service with the DSCSA solution vendor. If The Pharmacy wishes to discontinue the Service, it shall contact RedSail promptly in writing. The Pharmacy understands that it is solely responsible for obtaining any applicable patient authorizations required to utilize the Service. Pharmacy acknowledges and agrees that the Service was not developed by, nor is it maintained by, RedSail. Pharmacy's use of the Service shall be governed by the terms and conditions entered into between the third-party vendor providing the Service and Pharmacy. RedSail is not responsible for any data or information provided by the Service or Pharmacy's use thereof and releases RedSail and its affiliates from any liability associated therewith.

This Service Request and Authorization is made via this form and enrolling through the link to be provided separately. Billing for the service will begin upon completed enrollment with DSCSA vendor and notification from the vendor. Fees will appear on the Pharmacy's monthly RedSail invoice and will be paid to RedSail. RedSail or the Pharmacy may terminate this Service Request and Authorization upon 30 days' prior written notice.

I attest and affirm that I am authorized to sign this Acknowledgement on behalf of the Pharmacy.

Authorized Signature*

Please use your mouse or touch screen to draw your signature.

Print Name*

Title*

Date*

Date

DSCSA, Acknowledgemnt Form, v1.2.docx

RedSail Technologies represents the Pioneer, QS/1 and Integra® brands.

SERVICE REQUEST AND AUTHORIZATION