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 Pharmacy Information
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 Address*    
 City*    
 State*    
 Zip Code*    
 DEA Number:     
 DEA Exp Date:     
 D & B Number:     
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 2nd Company Ref:    
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 3rd Company Ref:     
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Sales Rep
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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.

 

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