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IACP Drug Evaluation and Classification Program DRE INFORMATION UPDATE FORM DRE Name:____________________________________________________ DRE #: _______________________________________________________ Original Agency: _______________________________________________ Rank/Title: ____________________________________________________ Name Change: _________________________________________________ New Agency: __________________________________________________ New Agency Address: ___________________________________________ ___________________________________________ New Agency Phone Number: _____________________________________ Date Decertified: _______________________________________________ Reason Decertified: ____________________________________________ Agency (or State) Coordinator ____________________________________ Date _________________________ This form may be duplicated