New Customer Setup Form BEFORE YOU START: You will need to complete the credit card authorization form and upload it when you submit the Customer Setup Form below. Download the form, complete and save it, and you’ll be ready to add it to the form below. < Download the Credit Card Authorization Form * denotes a required field GENERAL INFORMATION Legal Entity Name* Primary Business Contact Business Phone* Accounts Payable Contact* Years in Business DBA Name (if any) Pharmacy in Charge* Business Email* Accounts Payable Email* Dun# SHIP TO INFORMATION Shipping Address State City Zip BILL TO INFORMATION Billing Address State City Zip LICENSE INFORMATION State Pharmacy License PIC License (Upload PDF or JPG) Additional Documents (Upload PDF or JPG) DEA License (Upload PDF or JPG) State Controlled Substance License (Upload PDF or JPG) Type of Customer* Retail PharmacyDr./Physician OfficeHospitalClinicNursing HomeLong Term CareDistributor340B ClinicRe-packageOther If other, Specify: Primary Wholesaler* Secondary Wholesaler* Credit Card Authorization Form Δ