VACCINE CONNECT

FOR MORE THAN ONE LOCATION, PLEASE FILL OUT THIS FORM FOR EACH LOCATION OR CALL US AT 843-973-2711 FOR ASSISTANCE.

PLEASE LIST PRIMARY/SECONDARY DISTRIBUTOR AND/OR WHOLESALER

(Not required for customers intending to purchase only directly from GSK)

CERTIFICATION:

The purpose of this paragraph is to confirm the buying group affiliation of the above named entity (the "Participating Member"). GlaxoSmithKline LLC ("GSK") will recognize only one buying group as the Participating Member's primary buying group for the purchase of GSK products. By identifying the buying group below as its primary buying group, the Participating Member hereby agrees to the terms and conditions of the buying group's contract with GSK, including without limitiation, GSK product pricing, and obligations and requirements related to such pricing. The Participating Member hereby acknowledges and agrees that its sole buying group for the purpose of purchasing GSK products is Vaccine Connect LLC (the "Group"). GSK has the sole discretion whether or not to accept this Declaration Form and permit the Participating Member to purchase GSK products under the Group contract. If the Declaration Form is accepted by GSK and Participating Member currently is not participating in any other contract with GSK, the Participating Member will be added to the Group contract. If Participating Member was previously participating in another GSK contract, except for the FLEX NON-ACUTE individual vaccine pricing agreement, it is understood that the Participating Member will be rejected from the Group identified above and shall remain in their current existing group affiliation. For Participating Members on FLEX NON-ACUTE individual vaccine pricing agreements, upon approval of this declaration form by GSK, the Participating Member shall be removed from the current group affiliation other than the Group identified above and will no longer be eligible for the pricing available to the prior group affiliation. The Group shall have the right to reject the addition of the Participating Member to the Group within 48 hours after notification by GSK of the addition of the Participating Member or at the beginning of a contract performance evaluation period. Upon expiry or termination of the Group contract, or if the Participating Member is removed from the Group at the Group's request, the Participating Member will be automatically enrolled in GSK's individual Vaccine Pricing Agreement ("iVPA") without any action required by the Participating Member. The Participating Member may discontinue participation in the iVPA or change to another GSK contract (subject to GSK approval) at any time.

By signing below, Participating Member certifies that all of the information on this form is true, correct, and complete. Further, Participating Member certifies and agrees that (1) any GSK product purchased under any agreement shall be for its "Own Use," as defined by the United States Supreme Court in Abbott Laboratories et al. v. Portland Retail Druggist Association, Inc. 425 U.S. 1 (1976), and Jefferson County Pharmaceutical Association, Inc. v. Abbott Laboratories, et al., 103 S. Ct. 1011 (1983), (2) it does not and will not prevent its wholesalers and distributors from reporting purchasing data to the GSK third party data source, (3) it permits and will continue to permit GSK sales force open and free access to their clinics for the legal promotion of GSK products, and (4) it will disclose and discounts received hereunder, including the contract prices and any passed-through ASFs as reductions in its acquisition costs for GSK Vaccines to the extent required by any government entity or private payor. In addition, Participating Member agrees that GSK may, in its sole discretion, contact its staff, and/or visit its' locations to verify that the above information is correct, and Participating Member agrees to provide such information to GSK as is reasonably necessary for GSK to make such a determination.

As a Participating Member,

• I understand that there are never any costs to join or be a member of Vaccine Connect.
• I wish to participate in Vaccine Connect's reward program and understand that Vaccine Connect's reward policy is available to read on their website, www.vacconnect.com.
• I agree that all products purchased through any Vaccine Connect agreement are for my own use.
• I understand that Vaccine Connect's contracted vendors may share my purchasing data with Vaccine Connect. Vaccine Connect will provide written notification of these sales to me no less than annually. I also understand that these vendors may pay Vaccine Connect an administrative service fee for operating and facilitating operations. This fee will never exceed 3% of my net purchases except in the case of Sanofi vaccines where the fee will not exceed 5.75%.
• I agree to keep all Vaccine Connect pricing confidential.
• I understand that Vaccine Connect intends to comply with all applicable state and Federal laws. As a group purchasing organization, Vaccine Connect is subject to applicable provisions of the Federal "Safe Harbor" regulations. It is my responsibility and intent to comply with all applicable state and Federal laws, including the Medicare and Medicaid anti-kickback statute and Federal "Safe Harbor" regulations.
• I acknowledge that this agreement shall remain in effect unless terminated by either party. Either party may terminate this agreement by providing written notice to the other party.

As a Participating Member, by signing below, I certify that all of the information on this form is true and acknowledge that I have read and accept the terms and conditions set forth above.