Prescript Pharmaceuticals Inc. Account Application
This account application must be completed to use our online services and prior to shipment of your first order or if there is a change in ownership. The information pertains to labeling, packaging, shipping and billing instructions that you authorize. Please review this information carefully (making any changes or corrections). Once approved we will Email you login information to access our online services.

*Required

*Name First:*Name Last:
*Email:
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 *Company:

*Address 1:
  Address 2:
        *City: *State: *Zip:
     *Phone:     EXT:
          Fax:     EXT:

Prescriber Name:



 
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Contact Name: Phone: Fax:

      Address 1:
      Address 2:
             City: State: Zip:


If ordering controlled substances, please fax or mail a copy of your current D. E. A. license. (must be shipped to address on certificate)
 MED Licensee:State License#:
Exp. date:
DEA Licensee:      DEA Reg.#:
Exp. date:
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      Name:
Address 1:
Address 2:
       City:State: Zip:

 

Phone: ext:
   Fax: ext:
Payment Terms: Net-30
Credit line requested:
Pay with credit card
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O		          Legal Name:
      Owners Name:
Trade Reference1:
Address:Phone:Account#:
Trade Reference2:
Address:Phone:Account#:
Trade Reference3:
Address:Phone:Account#:
Bank Reference:
Address:Phone:Account#:
Type of business? CorporationPartnershipSole Proprietor
 Tax Exempt Tax ID#:
 

 

  

Upon submitting this information, it is understood that Prescript Pharceuticals Inc. is authorized to investigate credit of the applicant. Terms of sale: Full amount is due (30) thirty days from invoice date. There is a one and half 1 1/2) percent charge on any balance after the due date. In the event of delinquency applicant agrees to pay all reasonable collection and/or attorney's fees & costs (including finance charges) incurred in the collection of this account. The applicant affirms that there exists the financial ability to meet any commitments made and will pay Prescript Pharceuticals Inc. according to the terms stated above.