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Financial Information
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| Legal Entitiy Responsible for Payment |
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| Legal Entitiy Federal Tax ID |
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| Dun & Bradstreet # |
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| State of Incorporation or Registration |
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| Organization ID # Issued by State |
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| State of Chief Executive Office |
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| Years in Business |
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| Corporation Type * |
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*Officer information required for Partnership or Sole Proprietorship account:
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Officer #1:
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| Name |
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| Title |
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| Home Address |
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| Home City |
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| Home State |
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| Home Zip Code |
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| SS# or Federal Tax ID# |
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Officer #2:
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| Name |
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| Title |
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| Home Address |
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| Home City |
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| Home State |
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| Home Zip Code |
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| SS# or Federal Tax ID# |
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Credit and Reference Information
To establish your desired credit limit, please attach 3 months of statements
for each trade reference.
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| The Alliance Pharmacy Account # (if applicable) |
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| Division # |
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Other Wholesaler/Distributor/Manufacturer:
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| Name |
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| Account # |
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| Contact |
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| Phone |
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Trade Reference #1:
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| Name |
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| Account # |
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| Contact |
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| Phone |
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Trade Reference #2:
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| Name |
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| Account # |
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| Contact |
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| Phone |
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Please estimate the anticipated amount of your monthly purchase from The Alliance
Pharmacy: (Please check most applicable.)
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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:
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If you are a legal entity and provide a physican license, we require a letter
of affiliated with the entity.
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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.
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Terms & Conditions
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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.
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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.
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Checking this box indicates your signature of this document:
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