Generic Pharmaceutical Wholesaler

Account Application

Select Account Type:
*Business Name:  
Bill To Ship To
*Address: *Address:  
*Address 2: *Address 2:  
*City: *City:
   *State: *State:
     *Zip: *Zip:
Check this box if Billing Address & Shipping Address are the same
  *Phone: *Fax:
*DEA #:   *Exp Date:
HIN #: (optional)    Exp Date:
*State License #:   *Exp Date:
Tax ID or SS#:
Ownership Type
Years Under Current Ownership
Business Type
Average Scripts per Day (or equivalency):   % of scripts billed to insurance:
Specialty:   Do you want labels?

AP Information
*Accounts Payable Name:   *Authorized Buyer Name:
*AP Phone:   *Buyer Phone:
*Do You Require Monthly Statements:      *How should the Statement be sent:   
Credit Limit Requested: $

Trade Reference Non-Drug Supplier
Name: Phone: Fax:
Name: Phone: Fax:
Officers or Owners
*Name:  *Position:
 Name:   Position:

Salesperson: Date Submitted:

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