New Custodiol® HTK Customer - Essential Pharmaceuticals

BILL TO:

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Customer Account #:

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Customer DEA # (If Necessary):

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SBP License #:

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Charge To #:

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Charge To Address:

Customer Name:*

Department or Attention To:*

Address:*

Street Address Address Line 2 City State ZIP Code

Email:*

Phone:*

Fax

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S/A Group:

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Pricing Group:

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Ship Via:

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Credit Limit:

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Terms Code:

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Salesman #:

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Territory Code:

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Taxable Entity:

SHIP TO:

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Ship To:

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Customer DEA # (If Necessary):

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SBP License #:

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Charge To #:

Ship To Customer Name:*

Department or Attention To:*

Shipping Address:*

Street Address Address Line 2 City State ZIP Code

Phone:*

Fax:

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S/A Group:

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Salesman #:

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Territory Code:

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Warehouse:

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BACCS:

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Approved By:

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Date:

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Entered By:

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Date:

Website:*

Physician requesting account to be opened:

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