New Account Questionnaire

We appreciate your interest in opening an account with Penn Veterinary Supply and we look forward to working with you.

Please provide answers to this short questionnaire so we can prepare the forms necessary to finalize the regulatory approval and setup of your account.

PLEASE NOTE: We sell only to licensed veterinarians or facilities with an authorizing veterinarian-of-record. Account setup requires proof of active veterinary licensure. We ship only within the continental United States. We do not ship to California, Hawaii, or Alaska.

Facility Name:

Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your primary shipping address different from your billing address?

Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have other alternate shipping addresses?

How many alternate shipping addresses do you have?

Contact Name (Name of person who should receive forms)

First NameLast Name

Email Address (Email address to receive forms)

example@example.com

Phone Number

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

Which of these best describes your facility?

Do you have a veterinarian on staff?

Is the owner/financially responsible party also the veterinarian of record for the facility?

Is your facility exempt from taxes?

Do you plan to purchase controlled substances?

Select your preferred payment terms:

Is your facility currently open?

Anticipated opening date or timeframe

How did you hear about us?