Please do not put Pharmacy:
Please upload your files before you submit the registration:
As required by state and federal law, please provide copies of (i) a valid DEA registration and (ii) a valid physician or pharmacy license and/or permit. In addition, per state and federal law:
EXTENSION OF CREDIT: Customer represents and warrants that all information contained herein is current, correct, and complete and that STAQ Pharma, Inc./STAQ Pharma of Ohio, LLC (STAQ) may rely on such information in deciding to extend or deny credit. Customer agrees to notify STAQ immediately, in writing, of any change in the foregoing information including, without limitation, any change in the nature of the business, licensure, registration name, location of the business, or financial condition. Customer authorizes STAQ to obtain written and oral credit reports from any credit reporting agency. Customer further authorizes any bank or commercial business with whom Customer is doing or has done any business with to give any and all necessary information to STAQ that will assist STAQ in the credit investigation. Customer further authorizes STAQ to reinvestigate Customers credit status from time to time as STAQ deems necessary and should STAQ upon such reinvestigation deem it necessary to limit or terminate the credit arrangement with Customer.
PAYMENT: Except as provided in writing by STAQ, terms of payment for all orders are Net - 30 days from date of invoice. Prices billed are the prices in effect at the time Customer orders product from STAQ. Prices are subject to change without notice. Credit card payments will incur a 4% surcharge. Customer agrees to pay all debts, accounts, and invoices owing to STAQ in full in accordance with the terms of the sale as set forth on the invoice. In the event such debts, accounts, or invoices owing are not paid when due, STAQ may, in addition to STAQs right to exercise other remedies, withhold any credits or payments to Customer and assess interest at the at a rate equal to the lower of eighteen percent (18%) per annum or the maximum rate allowed by law on the amount due until paid in full, beginning on the first business day after such due date. STAQ may charge a processing fee of $50.00 for any dishonored payment. Customer hereby agrees to pay all fees and collection costs including attorneys fees and expenses, in the event STAQ pursues a legal or collection action.
SHIPPING: Freight/shipping charges for UPS ground are included in the product price, subject to Customers minimum order of $1,000 per order. Customer shall pay for shipping on orders of less than $1,000. Additionally, Customer shall pay an additional shipping charge on orders requesting emergency and/or same day delivery of Product. STAQ will ship orders only to addresses reflected on a license that is current and valid under applicable law, or as otherwise permitted under applicable law.
GOVERNING LAW: This Application shall be construed and enforced in accordance with the laws of the State of Colorado, without reference to its principles of conflict of laws. Customer agrees that STAQ may bring any legal or equitable action against Customer, and that Customer shall bring any legal or equitable action against STAQ, in any court of general jurisdiction in Denver County, Colorado. Customer irrevocably consents to personal jurisdiction and waives any objection it may have to the laying of venue of any such action, in such court. Customer irrevocably agrees to service of process by certified mail, return receipt requested, to the address of Customer set forth on the attached business application or any related agreement.
WAIVER OF JURY TRIAL: EXCEPT AS PROHIBITED BY APPLICABLE LAW, THE PARTIES HEREBY WAIVE ANY AND ALL RIGHTS THEY MAY HAVE TO A JURY TRIAL IN CONNECTION WITH LITIGATION COMMENCED BY OR AGAINST STAQ WITH RESPECT TO THEIR RIGHTS AND OBLIGATIONS (1) UNDER THIS APPLICATION OR ANY OTHER AGREEMENT BETWEEN THE PARTIES AND (2) IN ANY MANNER CONNECTED WITH, RELATED TO OR INCIDENTAL TO TRANSACTIONS BETWEEN THE PARTIES, WHETHER SOUNDING IN CONTRACT, TORT OR OTHERWISE.
No modification or termination of this Application, or any part hereof shall be valid or effective unless agreed to and accepted in writing and signed by an authorized officer of STAQ.
Checking this box indicates your signature of this document:
I hereby warrant and represent that (i) the foregoing information is true and correct, (ii) I have the authority to bind Customer to the terms and conditions stated above, and (iii) Customer is liable for and will pay all invoice amounts, regardless of whether Customer is reimbursed by any insurer or other third party for the invoice(s) amount. Customer authorizes the release of credit information to The Alliance Pharmacy.