New User Registration
Username or Email Address:
Account Code or Customer Number:
If you have an existing account with us, Please enter it and we will associate your login with your account. (Leave Blank if you do not have one)
First Name:
Last Name:
New Customer Information
Hospital/Facility Name:
Group Purchasing Organization (GPO):
Integrated Delivery Network Name (IDN):
Ship To Address
Shipping Address 1:
Shipping Address 2:
City:
State:
Zip Code:
Attention Location (Suite/Room/Person)

Please do not put Pharmacy:

Pharmacy Phone Number:
Additional Notes:
Licensing Information - please send pdf of all licenses
Pharmacy License#:
Pharmacy License Expire:
DEA License#:
DEA License Expire:
CSOS DEA Signing Authority:
Controlled substance order method
CSOS will not only increase compliance at your hospital, but will also reduce paperwork and decrease time taken for order fulfillment
Electronic CSOS:
Billing Information
Attention To:
Billing Address 1:
Billing Address 2:
Billing Address 3:
City:
State:
Zip Code:
Pharmacy Invoice Email:
Accounts Payable Contact (Billing)
Contact:
Phone:
Fax :
Email:
Invoice Receipt Method:
Special Set up Instruction if any:
Contacts
Director of Pharmacy:
Order Contact:
Business Contact (Vendor Accounts)
Contact:
Phone:
Email:
Recall Coordinator (In the event of a Recall)
Contact:
Phone:
Email:
Financial Information
Legal Entitiy Responsible for Payment
Legal Entitiy Federal Tax ID
Dun & Bradstreet #
State of Incorporation or Registration
Organization ID # Issued by State
State of Chief Executive Office
Years in Business
Corporation Type *
*Officer information required for Partnership or Sole Proprietorship account:
Officer #1:
Name
Title
Home Address
Home City
Home State
Home Zip Code
SS# or Federal Tax ID#
Officer #2:
Name
Title
Home Address
Home City
Home State
Home Zip Code
SS# or Federal Tax ID#
Credit and Reference Information
To establish your desired credit limit, please attach 3 months of statements for each trade reference.
The Alliance Pharmacy Account # (if applicable)
Division #
Other Wholesaler/Distributor/Manufacturer:
Name
Account #
Contact
Phone
Trade Reference #1:
Name
Account #
Contact
Phone
Trade Reference #2:
Name
Account #
Contact
Phone
Please estimate the anticipated amount of your monthly purchase from The Alliance Pharmacy: (Please check most applicable.)

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:
  • If you are a legal entity and provide a physican license, we require a letter of affiliated with the entity.
  • If you provide a physician license and the address on the license does not match the above shipping address, we require a letter of affiliation certifying that the physician is affiliated with the shipping address.

Terms & Conditions
TERMS: This business application (Application) is submitted to STAQ Pharma, Inc. (STAQ) for the purpose of obtaining credit. Customer represents and warrants that all information contained herein is current, correct, and complete and that STAQ may rely on such information in deciding to extend or discontinue 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, ownership, 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 Customer?s 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 is invoiced by STAQ. Prices are subject to change without notice. Prices on invoices reflect a discount for payment by cash, check, EFT or similar means other than the use of a credit card, unless otherwise noted. 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 STAQ?s right to exercise other remedies, withhold any credits or payments to Customer and assess a perday late payment fee 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 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.
ORDERS AND SHIPPING: Customer shall pay an additional shipping charge applicable to 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.
OWN USE: Customer shall pay an additional shipping charge applicable to 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 TAP 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.

AUTHORIZED SIGNATURE REQUIRED
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.
Checking this box indicates your signature of this document:

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