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
Would you like to add a new purchasing contact?
Purchasing Contact Name

First NameLast Name
Purchasing Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Purchasing Contact Email
example@example.com
Would you like to add a new accounts payable contact?
Accounts Payable Name

First NameLast Name
Accounts Payable Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Accounts Payable Email
example@example.com
Will this location purchase any kind of drug product (OTC, RX, or CS)?
Upload a copy of each applicant’s DEA Registration. (If you do not have access to the documents at this time, you may still submit this form; however, you will be unable to make purchases until we have received the registrations.)

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Upload a copy of each applicant's State Professional License. (If you do not have access to the documents at this time, you may still submit this form; however, you will be unable to make purchases until we have received the Licenses.)

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Upload a copy of each applicant's State Controlled Substance Licenses. (If you do not have access to the documents at this time, you may still submit this form; however, you will be unable to make purchases until we have received the Licenses.)

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you plan to use a NEW credit card to make purchases for this location?
*You do NOT need to add any additional credit card information to this form. We will contact you for payment details at the time of your first purchase.
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
Title
Printed Name

First NameLast Name
Should be Empty: