Create New Account 6.2

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:

Shipping Instructions:

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.)

Upload Documents With Your Registration

View Uploaded Documents

Please upload your files before you submit the registration:

Web Login to Copy Profile from :

Terms & Conditions

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: 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:

Once your new login is created we will email you a new password. Don't worry, you can change it once you login. Please review the messages below after you click register.

Status Message:
Please Enter your Information Above and Click Register New User to create your new user account.

NEW USER REGISTRATION

New Customer Information

Ship To Address

Licensing Information - please send pdf of all licenses

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

Billing Information

Accounts Payable Contact (Billing)

Contacts

Business Contact (Vendor Accounts)

Recall Coordinator (In the event of a Recall)

Financial Information

Officer #1:

Officer #2:

Credit and Reference Information To establish your desired credit limit, please attach 3 months of statements for each trade reference.

Other Wholesaler/Distributor/Manufacturer:

Trade Reference #1:

Trade Reference #2:

Please estimate the anticipated amount of your monthly purchase from The Alliance Pharmacy: (Please check most applicable.)

Upload Documents With Your Registration

Terms & Conditions

Once your new login is created we will email you a new password. Don't worry, you can change it once you login. Please review the messages below after you click register.

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

Credit and Reference Information
To establish your desired credit limit, please attach 3 months of statements for each trade reference.