DHMS

First Name *

Last Name *

Email *

Type Of Business *

Business Name *

DBA *

Purchasing Contact *

AP Contact *

Email *

Doctor's Name *

Speciality *

Hours Of Operation *

Sales Tax Exempt *

Yes No

Exemption Certificate *

Permitted files types: JPG, PNG

Local Tax Rate *

DEA *

State Lincese *

State Control Drug *

Upload DEA license

Permitted files types: JPG, PNG

Upload State license

Permitted files types: JPG, PNG

If you dispense medication in your office please provide a copy of your state dispensing license.

ATTN: Nurse Practitioners

If your state requires a collaborating physician, you MUST submit your collaborating physician’s license and a legend drug and device authorization form also.

Check Type Of Payment Desired *

Card Number

Expiry Date

CVV

Address

City

Country

State

Zip

Shipping Address *

Shipping City *

Shipping Country *

Shipping State *

Shipping zip *

Shipping Phone *

Shipping Fax

Same as Shipping Address

Billing Address

Billing City

Billing Country

Billing State

Billing Zip

Billing Phone

Billing Fax

An invoice of your purchase is processed and sent with your order. A statement will be sent. ACH EOM debits will be initiated between the 10th and 15th of each month (if selected). Any NSF's will incur a $25.00 charge.

If NSF occurs twice your payment terms will be changed. Late fees are 1.5% of monthly past due balance.

Company *	Address	Account #	Telephone #	Fax #

Name *

Title *

I am an Authorized Officer of the Business with the authority to bind the Business listed above to the terms of this Agreement. The execution, delivery, and performance of this Agreement have been duly authorized. I will provide the evidence of such authorization upon request. I understand that the Business and I are individually and jointly liable for paying charges on the Account according to the Terms and Conditions set forth.

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Password *

Contact Information

General Information

Account Payment Method

Shipping Address Information

Billing Address Information

Membership Business Trade References

Authorized Officer Signature

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