ASAP 5.0 Extension Request Form

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* 1. Contact Information

First Name

Last Name

Email address

Entity Name

Pharmacy Software Vendor

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* 2. Please enter the proposed ASAP 5.0 transition date (no later than Dec 31, 2026):

Date / Time

Date

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* 3. Reason for Extension Request:

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* 4. Proposed Plan to meet new deadline (outline basic steps to complete the work):

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* 5. Any other comments or concerns you'd like to share?