Credit Application V2

Select Credit Limit*
If other, enter requested Credit Limit
Select Payment Option*

Credit/ACHPrepayMail Check
Mail checks to:

Independent Pharmacy Distributor

P.O. Box 896827

Charlotte, NC 28289-6827

*Checks received after the 10th of each month will be considered late*
To finalize setup:

Credit Card/ACH Authorization forms must be completed. Click the appropriate link to complete Credit Card/ACH Authorization Form:

ACH-Manual Option

ACH- Automatic Option

Credit Card Authorization Form
Agreement

(By checking these boxes you are agreeing to our terms - should you have any questions please contact us)
Owner's Name:*

First NameLast Name
Owner's Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Owner's Phone Number*
Please enter a valid phone number.
Owner's Driver's License Number:*
Upload A Copy Of The Owner's Driver's License:*

Cancelof
Signature of Owner (Full Name)*

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Date*

MonthDayYear
Date
Independent Pharmacy Distributor, LLC

_____________________________________
Russell Patterson, President, by

_____________________________________
Katie Graham, Power of Attorney

_____________________________________
Date
Math Challenge*
Should be Empty:

Credit Application