PAH ACCOUNT APPLICATION

ACCOUNT APPLICATION

Commercial Credit Application
APPLICANT INFORMATION
Legal Business Name:*
Does your company use a Business DBA Name?*

YesNo
Business DBA Name:
Purchaser Name:*
Purchaser Email:*
Phone Number:*
Fax Number:
Business Entity Type:*

CorporationSole ProprietorshipPartnershipLimited Liability Company (LLC)Other
Owner Name:*
Year Business Started:
Tax ID:
Shipping Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Is your billing address the same as your shipping address?*

YesNo
Billing Address:

Street Address

Street Address Line 2

CityState

Zip Code
Accounts Payable Name:*
Accounts Payable Email:*
Accounts Payable Phone Number:*
LICENSE INFORMATION
DVM Licensee Name:*
DVM Licensee Number:*
DVM License Expiration Date:*

MonthDayYear
DEA Licensee Name:
(Required with KYC)
DEA Licensee Number:
(Required with KYC)
DEA License Expiration Date:

MonthDayYear
(Required with KYC)
HCCE Permit Name :
(Florida Only)
HCCE Permit Number :
(Florida Only)
HCCE Permit Expiration Date :

MonthDayYear
(Florida Only)
ADDITIONAL INFORMATION
Does applicant belong to any of the following groups?

AmerivetBluePearlCompassion FirstEthosHeartlandInnovetiveMedVetMVPNVAPathwayPetVetRarebreedSVPVCAVet at Your DoorVetCorVEGVGPVHAVMGWellHavenOther
Primary Wholesaler:

AmatheonCovetrusMWIPattersonVictor MedicalPenn VetFirst VetMidwest VetOther
How did you hear about Pharmsource Animal Health?

FacebookVetcoveReferralOther
Number of Doctors
If PAH has important information to share, please provide an additional email address where we can send updates (if applicable):
TERMS AND CONDITIONS
Applicant (Legal Business Name)*
Date*

MonthDayYear
Date
Authorized Representative Name*
Authorized Representative Title*
Authorized Representative Signature*

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PERSONAL GUARANTY
Guarantor Name*
Date*

MonthDayYear
Date
Guarantor Signature*

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Optional: Upload a copy of your DVM license and any other relevant documents.

While this is optional for this form, providing these documents may help expedite the processing of your application.
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Select your Pharmsource Account Manager (if applicable):
Should be Empty:

ACCOUNT APPLICATION

APPLICANT INFORMATION

LICENSE INFORMATION

ADDITIONAL INFORMATION

TERMS AND CONDITIONS

PERSONAL GUARANTY