Please read all information carefully

1) "Bill To" Account Information
   (if No, attach tax-exempt resale certificate title)

2) "Ship To" Address

3) Bank Reference

4) Pharmaceutical Credit Reference
 


 

5) Estimated Monthly Purchase

(Please check appropriate box)


6) Type of Facility the Product will be shipped to

(Please check the most appropriate box)


7) Licensing

8) DEA and HIN