Create New Account 6.2

NEW USER REGISTRATION

If your Hospital has an account with us, please reach out to your sales representative for account details or email orders@staqpharma.com. This form is for New Customers.

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

Username:

Email Address:

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:

Pharmacy Phone Number:

Licensing Information - please send pdf of all licenses

Pharmacy License#:

Pharmacy License Expire:

DEA License#:

DEA License Expire:

Authorize DEA CSOS Signer:

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

Paper E222 form to be Emailed to Staq Pharma 14135 E 42nd Avenue Denver Co 80239

Electronic CSOS:

Billing Information

Attention To:

Billing Address 1:

Billing Address 2:

Billing Address 3:

City:

State:

Zip Code:

Accounts Payable Contact (Billing)
Any AP questions Email : ap@staqpharma.com

Accounts Payable Contact (Only):

Phone:

Email:

Invoice Receipt Method:

Contacts

Director of Pharmacy:

Email:

Phone Number:

Pharmacy Buyer

Contact:

Phone:

Email:

Recall Coordinator (In the event of a Recall)

Contact:

Phone:

Email:

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

Financial Information

Legal Entity Responsible for Payment

Legal Entity Federal Tax ID

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:

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 #

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, per state and federal law:

If Customer is a legal entity and provided a physician license, please provide a letter of affiliation with Customer.
If Customer provided a physician license and the address on the license does not match the above shipping address, please provide a letter of affiliation certifying that the physician is affiliated with the Customer at the shipping address.

EXTENTION 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 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 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 STAQ's 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.

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. If Customer is buying Desmopressin from STAQ through The Alliance Pharmacy, Customer authorizes the release of information provided to STAQ 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 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) Any AP questions Email : ap@staqpharma.com

Contacts

Pharmacy Buyer

Recall Coordinator (In the event of a Recall)

Upload Documents With Your Registration

Terms & Conditions

Financial Information

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

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

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

Accounts Payable Contact (Billing)
Any AP questions Email : ap@staqpharma.com

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