Domestic Non-Pharma Applicationnationaldrugsource2020-07-19T18:26:59+00:00

New Customer Application

11. Company Details
22. Financial Details
33. Billing Details
44. Shipping Details
55. Purchasing Details
Company Details
Company Name *
Address *
Address Line 1
Address Line 2
City
State
Zip Code
Company Phone *
Company Fax
Company Website
Company EIN or TIN
The above-named company is a subsidiary?
Yes
No
Parent/Holding Company Name *
Parent Company EIN or TIN
Parent Company Phone *
Key Contact Details
Main Contact Name *
First
Last
Main Contact Phone *
Main Contact Fax
Main Contact Email *
Financial Details
Finance/Credit Control Contact Name *
First
Last
Finance Contact Phone *
Finance Contact Fax
Finance Contact Email *
DUNS#
Resale Tax Certificate ID#
Billing Details
Billing Address Same as Company Address Provided
Yes
Billing/Invoicing Address *
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country
Billing Contact Name *
First
Last
Billing Contact Phone *
Billing Contact Email *
Shipping Details
Shipping Address Same as Company Address Provided
Yes
Shipping Address *
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country
Shipping Contact Name *
First
Last
Shipping Contact Phone *
Shipping Contact Email *
Purchasing Details
Purchasing Contact Name *
First
Last
Purchasing Contact Email *
Purchasing Contact Phone *
Verification Documents Upload
File Upload

Click or drag files to this area to upload. You can upload up to 20 files.

Please provide all necessary documents listed on the Open An Account page for your business (.PNG, .JPG, or .PDF files only).
Name