Your electronic signature or digital signature is required when requesting drug samples offered on the MySampleCloset.com® website or mobile application/website in order to comply with the provisions of the Prescription Drug Marketing Act ("PDMA").

Under 21 CFR Part 11, an electronic signature must include at least two distinct identification components. On MySampleCloset.com®, your electronic signature is executed through secure, multi-factor authentication credentials unique to your account. This method is strictly for your professional use to request drug samples and product information. For the MySampleCloset.com® mobile application, your signature is captured as a digital representation of your handwritten signature recorded directly via your mobile device.

I certify that I am the person named above and agree to sign this document. I understand that this electronic signature is the legal equivalent of my handwritten signature and is acceptable in the court of law. I understand that it is illegal to sign this document on behalf of the person named above or to steal the identity of this person.

I also certify that I am a licensed practitioner with the proper federal and state authority to request these drug samples. These drug samples are requested for the needs of my patient. I understand that it is illegal to sell, trade or barter any drug samples and/or drug coupons. It is illegal to bill Medicaid or Medicare for free drug samples provided to me.