Hospital — New Account Setup Form — Nivagen Pharmaceuticals

Hospital - New Account Setup Form

HOSPITAL INFORMATION

Company Name *

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone *

GPO for Purchasing (if any) *

Tax Exempt No. *

HIN *

MAIN ACCOUNT CONTACT

Primary Contact Name *

Email *

Phone *

ACCOUNTS PAYABLE CONTACT

Primary Contact Name *

Email *

Phone *

BILLING INFORMATION

Company Name *

Street Address *

City *

State *

Zip Code *

Email *

ORDER PURCHASING

Ordering Method *

Buyer Contact Name *

Email *

Phone *

SHIP TO LOCATION

Use Hospital Address for this Ship-To location

SHIP TO LOCATION 1

Name *

Street Address *

City *

State *

Zip Code *

Phone *

State License

License No.

DEA License

License No.

Class of Trade *

Receiving Department Contact (Optional)

Name

Phone

CERTIFICATION & SIGNATURE

I hereby certify that the information provided in this application is complete, true and correct to the best of my knowledge.

Name *

Title *

Date *