Additional Location/Individual/Department Information Form

Additional Location/Individual/Department Information Form

Please complete this form to provide information about your organization's new location. These details help us verify affiliations and accurately manage shipping, billing, and communication.
Parent Organization's HPS Account Number*
Company name of NEW location (Include city or department of new location if applicable)*
Name of Individual completing this form*

First NameLast Name
Title of Individual completing this form*
Phone Number of Individual completing this form*
Please enter a valid phone number.Format: (000) 000-0000.
Email of Individual completing this form*
example@example.com
Person completing this form is also the applicant/admin for this location
Name of Primary Applicant/admin (or DEA registrant) for this location*

First NameLast Name
Title of Applicant*
Applicant's phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Email*
example@example.com
Human controlled substancesVeterinary controlled substancesNon-controlled human prescription drugsNon-controlled veterinary prescription drugsHuman over the counter drugsVeterinary over the counter drugsI will not be purchasing any type of drugs
Enter your Global Location Number (GLN) below
Name of your Attending Veterinarian:*

First NameLast Name
Attending Veterinarian's Email*
example@example.com
Attending Veterinarian's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
DEA Registration Number
Upload a copy of your DEA Registration

Cancelof
State Professional License Number
I am exempt from state licensure
Reason for exemption (such as animal research under an attending veterinarian)
Upload a copy of your State Professional License

Cancelof
State Controlled Substance Registration Number
I am exempt from state controlled substance licensure
Reason for exemption (such as animal research under an attending veterinarian)
Upload a copy of your State Controlled Substance License

Cancelof
Shipping Address (must match DEA Registration, if applicable.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
*After you submit this form, we will contact you for the credit card information at the time of your first purchase
My billing address is the same as my shipping address
Billing Address to be associated with NEW credit card

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any additional information you'd like us to know? (Hours of operation, preferred shipping method, etc.)
Attestation

I hereby attest that the information provided in this document is true, complete, and correct to the best of my knowledge and belief, and that no material facts have been omitted or misrepresented.
Signature*

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Title*
Printed Name*

First NameLast Name
Should be Empty: