Brand New Customer Registration Form

Full Name of Person Completing This Document

First NameLast Name

HIDDEN Name of Person Completing Application

Title

E-mail

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Company Fax Number

Format: (000) 000-0000.

Legal Business Name of Company or Organization:

Doing Business As (if applicable):

Year Established

Is {hiddenName135} also the purchasing contact? (The primary person who will be communicating with us to place each order)

Name of Primary Purchasing Contact:

First NameLast Name

Purchasing Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Purchasing Email

example@example.com

Is {hiddenName135} also the Accounts Payable contact? (The primary person to whom we should send invoices and contact for billing)

Name of Accounts Primary Payable Contact:

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Is {hiddenName135} also the Administrator in charge of this location?

Administrator in charge of this location

First NameLast Name

Administrator Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Administrator Email

example@example.com

What is the appropriate company email to notify in the unlikely event of a product recall?

example@example.com

Multiple Locations/Separate departments?

Other

*We will provide you a seperate, streamlined form to onboard your additional locations/seperate departments once we have established your account and verifies this initial entity.

Additional Contact Information - (optional)

In the Space above, feel free to share any additional information or special contact instructions.

Business Type

Please select from drop down menu.

If selecting "Other", please describe your Business Type

I am interested in Purchasing:

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.)

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 certain purchases until we have received the Licenses.)

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 certain purchases until we have received the Licenses.)

Enter your Legal Entity Global Location Number (GLN) - or type "don't know"

Enter the Global Location Number (GLN) for your primary shipping address - or type "don't know"

Hint: if you only have one location, these numbers might be the same

*A quick note about GLN compliance: as of August 2025, due to the U.S. Drug Supply Chain Security Act (DSCSA), any entity who purchases prescription drugs or controlled substances is required to have a GLN associated with their shipping address.

Company Federal Tax ID# or SS#

Primary Business Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your primary shipping address the same as your billing address?

Primary Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does your Company utilize Purchase Order Numbers?

Other

I would like to request the following Payment Method:

Other

Credit Cards are stored tokenized and will be billed automatically per invoice. *If you prefer to pay your full account balance (multiple invoices) all at one with a credit card, please select Net 30 terms. (Net 30 credit card payments can be completed via our online payment portal located under "Customer Resources" on our website.
- All credit cards will be preauthorized before being charged. This may appear on your banking platform as a "Pending" charge but will not post to your account.
- Resellers and Wholesale Distributors are not eligible for Credit Card payments without an additional 3% Convenience Fee added to the Customer Balance.
Net 30 require trade references and additional time for setup. Additionally, Net 30 invoices can also be paid via Credit card or E-Check via our Online Payment Platform, found under the "Customer Resources" tab on our website. A seperate Trade Reference Form will need to be completed to establish Payment Terms. This form can also be found under the "Customer Resources" tab on our website.

How did you hear about us?

Please Specify

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

Name

First NameLast Name

New Customer Registration Form

Nature of Business