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Forms

Instructions:
1. Fill out the form to the right and click "Submit" or print a .pdf version of this form and fill it out.

2. As the “contact name,” use the name of the person who will be handling the returns for your facility. INCLUDE A PHOTOCOPY OF YOUR FEDERAL DEA LICENSE FOR OUR RECORDS.

3. Under “Wholesaler Information,” ﬁll in ALL the requested information, and be sure to include your Wholesaler Account Number. If you purchase through more than one Wholesaler, ﬁll in the information of the Wholesaler you want your credit(s) to be issued through. COST CODES ARE REQUIRED TO INSURE THE ACCURACY OF YOUR RETURN.

Customer Information Form

If you'd prefer, you may also print a .pdf version of this form and fill it out.

Customer Information
Facility Name :
Address:
City:		State:
Zip Code:
Phone #:
Fax #:
Contact Name:
DEA #:
Exp. Date:
Cost Code:

Wholesaler Information
Wholesaler Name:
Address:
City:		State:
Zip Code:
Phone #:
Account #:

Direct Accounts
Manufacturer:
Account #:
Manufacturer:
Account #:
Manufacturer:
Account #:

NOTE: Please print before submitting if you'd like to retain a copy for your records.