Customer Onboarding Application

Business Name:*

Phone Number:*

Business Email:*

Global Location Number: (13-digit GLN issued by GS1)*

Type N/A if none.

Mailing Address:*

Mailing Street Address

Mailing Street Address Line 2

Mailing CityMailing State / Province

Mailing Postal / Zip Code

Is your billing address the same as your mailing address?*

YesNo

Billing Address:*

Billing Street Address

Billing Street Address Line 2

Billing CityBilling State / Province

Billing Postal / Zip Code

Does your hospital use a fax machine?*

YesNo

Hospital Fax Number:*

1st Authorized Contact's Name:*

First NameLast Name

Job Title: (Select all that apply)*

Would you like to add another authorized contact?*

YesNo

2nd Authorized Contact's Name:*

First NameLast Name

Job Title: (Select all that apply)*

Would you like to add another authorized contact?*

YesNo

3rd Authorized Contact's Name*

First NameLast Name

Job Title: (Select all that apply)*

Additional Doctors on Staff (if any):*

Type N/A if none.

Type of Business:*

IndividualPartnershipCorporationOther

Type of Hospital: (Select all that apply)*

Does your practice order controlled substances?*

YesNo

Which controlled schedules does your practice order and handle? (Select all that apply)*

IIIIIIVV

Hospital Special Instructions: *

I.e. Operating Hours, Delivery Schedule, Facility Security

Veterinary License Number (DVM License):*

License Expiration Date (DVM License):*

MonthDayYear

Upload Your DVM License:*

Upload a File

Does any practice DVM or the practice itself own another veterinary practice, or is in a partnership with another veterinary practice?*

YesNo

Secondary Hospital Name:*

Secondary Hospital Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Tax ID Number:*

Is Hospital Tax Exempt?*

YesNo

Upload your tax exemption resale certificate:*

Upload a File

Website Access Email Address (for online login & ordering):*

example@example.com

Payables Contact Name:*

First NameLast Name

Payables Email Address (to receive statements):*

Payables Phone Number:*

Area CodePhone Number

TERMS: Net-30. Payments are due upon receipt of goods. Please make checks payable to Amatheon Animal Health. In the event of default in payment of any amount due and if the account is placed with an attorney or collection agency, an additional charge equal to the cost of collection including agency, attorney fees, and court costs incurred will be added to your balance with finance charges to the extent permitted by law. Applicant authorizes Amatheon Animal Health to obtain a written or oral report from any reporting agency. Accounts with past due balances may be subject to a change in terms of either C.O.D. or payment by credit card. Only a corporate officer or owner can sign this form.

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Messaging frequency may vary. Reply ‘STOP’ to opt-out of future messaging. Message & Data rates may apply. Reply ‘HELP’ for more information. Privacy policy available at: https://www.amatheon.com/privacy-policy)

ALL ITEMS ARE SOLD ON A NON-RETURNABLE BASIS.

PERSONAL GUARANTEE: In order for Amatheon Animal Health to accept this application and otherwise sell to and/or extend credit to the undersigned applicant, the Applicant hereby agrees to personally guarantee and assume all of the obligations and responsibilities for any and all debts that the applicant shall incur including costs of collection, interest, attorney’s fees and court costs in connection with the applicant’s purchases from Amatheon Animal Health. commencing from the date of this application until such time as Amatheon Animal Health acknowledges, in writing, the termination of said extension of credit. The undersigned hereby agrees to notify Amatheon Animal Health of any changes in ownership and affirm that the financial condition of the applicant is satisfactory to meet all of its financial obligations. In the event of any suit for collection, the Applicant and each Personal Guarantor hereby consent to the jurisdiction of the Courts of the State of Florida with venue in Miami-Dade County, Florida, and waive all right to trial by jury.

By clicking submit you agree to submit your application as an Amatheon customer and agree to receive all marketing communications in addition to those for listed billing, and alternate authorized contacts. You also ascribe that you have read and agree to all of the terms and conditions stated above. The undersigned accepts and acknowledges that Amatheon Animal Health will use the information above and the signature below as authorization to engage in marketing communications with those contacts.

I have read and agreed to the terms above.*

Yes

Your Signature *

Will You Be Purchasing Controlled Substances?*

YesNo

By signing this form with your digital signature below, I hereby authorize Amatheon Animal Health to charge my credit card for all orders shipped to the Business Name and Shipping Address referenced above. I also certify that I am the authorized holder and signer of the credit card referenced above. Any change to the information listed on this authorization form must be submitted in writing to info@amatheon.com. Any such changes must be confirmed by Amatheon Animal Health in writing.

Digital Signature*

First NameLast Name

Business Name:*

Type of Practice:*

NewEstablishedPurchase

If yes, Provide secondary Hospital Name (Must be Completed if yes)*

Setup forAutomatic Credit Card Billing?*

YesNo

Credit Card Billing Address:*

Credit Card Street Address

Credit Card Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

If you want to claim excemption from tax on resale items, please upload a copy of your resale certificate*

Upload a File

Bank Name:*

Bank Representative:*

Bank's Tel. Number:*

Banks' Fax Number:*

Bank's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Are you currently a member of VMG (Veterinary Management Group)?*

YesNo

Billing City:*

Billing State*

Billing Zip Code:*

How did you hear about Amatheon?*

Please provide VMG Member Name*

Who is your Primary Veterinary Supply Vendor?*

MWI Vet SupplyButler Schein Animal HealthPatterson (Webster) Animal HealthOther

Customer Information

How would you like to receive your statements?*

EmailFax

Email Address for Statements*

Mailing Address:*

Mailing City:*

Mailing State*

Mailing Zip Code:*

Is your Mailing Address the same as your Billing Address?*

YesNo

Billing Address:*

Fax Number for Statements*

DEA Registration Number:*

DEA Registrant Name:*

License Expiration Date*

MonthDayYear

Upload Your DEA License*

Upload a File

Address listed on DEA Registration*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Practice Type:*

Days of the Week Open:*

Hours of Operation:*

Average Monthly Patients:*

1. Will Amatheon be your sole provider of Controlled Medications?*

YesNo

If No, what percent will you be purchasing from Amatheon?*

2. On average when do you order Controlled Medications? If Other, please explain.*

3. Are the medications being ordered solely for the registrar or for the entire clinic?*

4. Is anyone else authorized to sign 222 Order Forms for the registrant? If yes, please provide the power of attorney granting the authorization.*

YesNo

Upload Your Power of Attorney Document*

Upload a File

Do you have a pending order?*

YesNo

Who did you speak with?*

What are you interested in ordering?*

Are there any special instructions you'd like us to know while we set up your account?*

Please provide your email address*

Confirmation Emailexample@example.com

Phone Number*

Area CodePhone Number

Amatheon Animal Health Customer Onboarding Form