User Name:
Password:
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Pharmacy or Physician Information
Pharmacy Name:
Doing Business as:
Phone Number:
Fax Number:
Email:
Address:
City:
State:
Zip:
DEA Number:
DEA Exp Date:
D & B Number:
Years in Business:
Bus Lic Number:
Bus. Type
Sole Propietorship
Partnership
Corporation
State
Name of the Pharmacist or Physician
Pharmacist's Name:
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Purchasing Contact
Contact Name:
Contact Phone:
Provide Three References
1st Company Ref:
Phone:
2nd Company Ref:
Phone:
3rd Company Ref:
Phone:
Sales Rep
Sales Rep Name:
By applying for credit you acknowledge responsibility for payment by both your corporation, if any, and yourself individually. Unless otherwise stated in writing, all purchases made on or before the 25th, are due on the 10th and payable on the 10th of the following month. Purchases made after the 26th, are due on the 10th of the month after. In case of default, you agree to all reasonable collection and/or attorney fees. The above information is herewith submitted for the purposes of opening an account, and you do certify this information to be true.
