New Customer Registration - BioCare Portal

1) "Bill To" Account Information

Legal Business Name:

Primary Phone Number:

Fax:

Billing Address:

City:

Zip:

Country:

State:

Purchasing Contact Email:

Purchasing Contact Name:

Phone:

A/P Contact Email:

A/P Contact Name:

Phone:

Password:

Confirm password:

Taxable?:

Yes

No (if No, attach tax-exempt resale certificate title)

Legal Business Type:

Corporation

Partnership

Proprietorship

LLC

501 C3 (non-profit)

Federal ID#:

DUNS #:

Authorized Officer Name, Title, and Phone #:

2) "Ship To" Address

Delivery Address:

City:

Zip:

Country:

State:

Phone:

Fax:

Contact Name:

Email Address:

3) Bank Reference

Bank Name:

Account#:

City:

Zip:

Country:

State:

Phone:

Fax:

Contact Name:

Email Address:

Have you filed for bankruptcy or are there any suits, liens or judgments filed against the organization?:

Yes

Person Authorized to Release Bank Information

4) Pharmaceutical Credit Reference

Name:

Account#:

How long?

Contact Name:

City:

Zip:

Country:

State:

Phone:

Fax:

Name:

Account#:

How long?

Contact Name:

City:

Zip:

Country:

State:

Phone:

Fax:

Name:

Account#:

How long?

Contact Name:

City:

Zip:

Country:

State:

Phone:

Fax:

5) Estimated Monthly Purchase

(Please check appropriate box)

$0-$5,000

$5,001-$20,000

$20,001-$50,000

$50,001-$100,000

$10,0001-$250,000

$250,000+

Is your organization a member of a group purchasing organization (GPO)?

Yes

If Yes, Primary affiliation

BioCARE, Inc. New Account and Customer Credit Application

1) "Bill To" Account Information

2) "Ship To" Address

3) Bank Reference

4) Pharmaceutical Credit Reference

5) Estimated Monthly Purchase

6) Type of Facility the Product will be shipped to

7) Licensing

8) DEA and HIN

Account