FAIRFAX PHARMACEUTICAL WHOLESALER INC NEW CUSTOMER APPLICATION

Transcription

1 FAIRFAX PHARMACEUTICAL WHOLESALER INC NEW CUSTOMER APPLICATION

2 PLEASE PRINT OR TYPE SECTION A- GENERAL INFORMATION Business/trade name: Business/trade address: SECTION B- FINANCIAL INFORMATION -Type of Owner Ship: Proprietorship Partnership Corporation LLC State of Incorporation -Legal Partnership or Corporate Name of Business: -Federal Tax I.D. Number: State I.D. Number: o Shipping address ( check the box if same as above ) Primary Business Contact: Title: Primary Purchasing Contact: Title: Business Telephone Fax#: Major Suppliers/ Existing Wholesalers Supplier: Address: Phone: Contact: Supplier: Address: Phone: Contact: Name of Banks

3 Bank: City: State: Phone: Account Officer: Account#: Bank: City: State: Phone: Account Officer: Account#: Type of Business Retail Pharmacy Hospital Pharmacy Nursing Home Long-term Facility Outpatient Clinic Distributor Years in Business: Avg Monthly Script Volume: Avg Monthly Generic Sales: $ Avg Monthly Brand Sales: $ SECTION C- AGREEMENT and DISCLOSURES -As an inducement for Fairfax Pharmaceutical Wholesaler Inc. ( Fairfax Pharmaceutical ) to accept orders from or otherwise extend or make available credit to Applicant, which includes all Applicant owned stores as listed in Exhibit A attached hereto, the undersigned Applicant hereby agrees to comply with the following terms of sale, should Fairfax Pharmaceutical elect to extend such credit. -Pricing and payment terms are determined at the time an offer is presented to Applicant and as reflected on any accompanying invoice. - If Fairfax Pharmaceutical does not receive payment in accordance with the payment terms or based upon credit considerations deemed relevant to Fairfax Pharmaceutical, then Fairfax Pharmaceutical may refuse to deliver the product covered by this Agreement (the Product ), refuse additional orders, modify payment terms, place the Applicant on C.O.D., modify Applicant s cost of goods, limit or terminate the extension of credit and will be entitled to any other remedies available at law or equity. Until the product is paid for in full, Fairfax Pharmaceutical retains title to said Product. The term Fairfax Pharmaceutical Wholesaler Inc. or Fairfax Pharmaceutical shall include all subsidiary and affiliated companies of Fairfax Pharmaceutical Wholesaler Inc. a California corporation.

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5 FAIRFAX PHARMACEUTICAL WHOLESALER INC. CREDIT APPLICATION AND AGREEMENT -All payments shall be made in full, in good funds, either by check or electronic funds transfer (either by wire or automated clearinghouse), and in accordance with the payment terms. Fairfax Pharmaceutical may assess a service charge calculated at the rate of 1.5% per month (or the maximum rate allowed by law, if such rate is less than 1.5% per month) on any amount not paid by Applicant to Fairfax Pharmaceutical when due under the terms of this Agreement from the first day of delinquency. Failure or delay by Fairfax Pharmaceutical to bill Applicant for any such service charge will not waive Fairfax Pharmaceutical s right to receive the same. In the event of default in payments on any invoices, Fairfax Pharmaceutical shall the right to declare all invoices immediately due and payable and Applicant gives Fairfax Pharmaceutical the authorization to use any credit card, debit card or electronic funds transfer to satisfy any past due invoices. Applicant shall pay all out-of-pocket expenses, including attorney s fees and disbursements, incurred by Fairfax Pharmaceutical to collect any amounts due under this Agreement or to otherwise enforce any of the terms of this Agreement. This agreement shall be governed by and construed in accordance with the laws of the State of California. Any claim or action for breach of this agreement shall be brought in the State or Federal courts in the State of California. -The Product is shipped FOB destination. Applicant s obligation to pay for Product begins on the date of shipment. Applicant agrees to place orders in the specified minimum dollar amount. If the order size is less than specified minimum, Applicant agrees to pay a minimum order charge. Fairfax Pharmaceutical reserves the right at all times to determine what Product it will carry based upon product quality, manufacturer indemnity, insurance, and other policies, and other standards determined by it, and may delete Product from its available inventory at any time. No Schedule II orders will be delivered other than in compliance with DEA regulation. Our customers may do returns within 20 days window and get the return to the driver 2.Print the return form from our website 3. Package the items in a bag and staple the RA form to it 4. Give the bag to our driver -Applicant attests to Fairfax Pharmaceutical that it is properly licensed with applicable state licensing agencies to receive, dispense, distribute and otherwise legal dispose of the Product. Applicant understands that by attesting to this, Fairfax Pharmaceutical is complying with the good faith inquiry standard to ensure that the Product is distributed to properly licensed and/or registered pharmacy locations. Prior to purchasing the Product form Fairfax Pharmaceutical hereunder, Applicant must provide Fairfax Pharmaceutical with copies of all such licenses and any renewals, revocations or other changes to the same. -Applicant agrees to all the terms and conditions of this Agreement. This Agreement, together with all invoices, purchase orders, and the exhibits and addenda thereto constitute the entire agreement and understanding of the parties with respect to the subject matter hereof and supersede all prior written and oral agreements, proposals, bids/bid responses, and understandings between the parties relative to the subject matter hereof. No changes to this Agreement or any purchase orders will be made or be binding upon either party unless made in writing and signed by each party. By signing this Agreement, Fairfax Pharmaceutical and Applicant each represent that it has the authority to bind its respective party to this agreement. -All information provided in this Application or otherwise submitted is true and correct and is being (or will be) furnished for the purpose of obtaining/ retaining credit from Fairfax Pharmaceutical. Applicant authorizes its banks and suppliers to release any and all information as requested by Fairfax Pharmaceutical so as to ascertain credit worthiness. Applicant shall provide Fairfax Pharmaceutical with financial statements and such further information as may reasonably form time to time. -If there is a lawsuit, Applicant agrees upon Fairfax Pharmaceutical s request to submit to the jurisdiction of the state court of Los Angeles County, California or to the jurisdiction of the United States District Court for the Southern District of California. As Fairfax Pharmaceutical may elect. Applicant further consents to venue in either of the preceding courts. SECTION D- AUTHORIZED SIGNATURE -Print legal name as it appears on the application By (authorized signature): Title: By (printed name of signatory): Date: SECTION E- GUARANTEE The undersigned Principal(s) of Applicant, by reason of their interest in Applicant and as an inducement for Fairfax Pharmaceutical to extend credit to Applicant, hereby jointly and severally, irrevocably, and unconditionally guarantee to Fairfax Pharmaceutical Wholesaler Inc. and its subsidiaries, affiliates and successors (each a Guarantee Party) and assigns the prompt and full payment ( and not merely the ultimate collectability) and performance of all obligations of Applicant to each Guaranteed Party, whether now existing or hereafter arising. The undersigned authorize Fairfax Pharmaceutical Wholesaler Inc. to verify this information and/or additional information by obtaining data from a credit reporting agency. If Applicant or its business is hereafter sold, this guaranty shall continue to all credit hereafter made available to that Applicant or its business (as the case may be) until such time as Fairfax Pharmaceutical Wholesaler Inc. has received 5 days advanced written notice (via certified mail, return receipt requested) that Applicant and/or Principal(s) will no longer be responsible for credit thereafter made available with the respect to the Applicant or its business. THE UNDERSIGNED ACKNOWLEDGES THAT HIS/HERS INDIVIDUAL CREDIT HISTORY MAY BE A FACTOR IN THE EVALUATION OF THE CREDIT HISTORY OF THE APPLICANT AND HEREBY CONSENTS AND AUTHORIZES THE USE OF A CONSUMER CREDIT REPORT ON THE UNDERSIGNED BY Fairfax PHARMACEUTICAL WHOLESALER INC. FROM TIME TO TIME AS Fairfax PHARMCEUTICAL WHOLESALER INC. MAY DEEM NECESSARY IN ITS CREDIT EVALUATIONS. By (Principle): By (Printed name of signature): Date:

6 By (Principle): By (Printed name of signatory): Date: Credit Limit: Payment Terms: Expiration Date: Approval: The term Fairfax Pharmaceutical Wholesaler Inc. or Fairfax Pharmaceutical or FFP shall include all subsidiary and affiliated companies of Fairfax Pharmaceutical Wholesaler Inc. a California corporation. Fairfax Pharmaceutical Wholesaler Inc. Controlled Information Survey (CIS) Sales Rep Name: Customer Acc Name: Customer Address: City/State/ZIP: Customer Acc Number: Reviewed by Fairfax Pharmaceutical Wholesaler Inc. Accepted: Declined: Signature: Date: Please FAX the completed Compliance Information Survey and STATE and DEA LICENSES Fax survey to (818) State and Federal Compliance Information Survey must be completed and faxed back before any controlled substances will be shipped. To ensure compliance with requirements of individual state licensing boards and to ensure compliance with the requirements of the Code of Federal Regulations on the sale of Controlled

7 Substances, Fairfax Pharmaceutical Wholesaler Inc. must perform due diligence on each customer where prescription and/or controlled substances are purchased. We ask that you complete the below questionnaire, attach information where requested and return the information. All information will be held in strict confidence. Some categories of controlled substances may have restricted quantitates and are shipped pending Compliance Review. Section A-State Governing Board and Licensing Information State of Licensure and type of license, e.g., pharmacy, practitioner, wholesaler, hospital,/clinic, etc. Enter your state license number and expiration date. Do not forget to attach a copyof your current state license At any time in the last 5 years have you been inspected by a state governing board, the State Board of Pharmacy or Medical Board? If yes, provide a separate sheet of paper stating the results of this inspection and corrective actions taken Are you currently under investigation by the Board of Pharmacy or Medical Board or any state governing board? If yes, please provide a synopsis of the investigation on a separate sheet of paper Have you or your company or business ever had a license denied, revoked or suspended by any state governing board? If yes, attach a separate sheet of paper stating the reason(s) for any of these actions Section B- General Compliance and Business Information Federal DEA Number and expiration. DO NOT forget to attach a Copy of Current DEA license Business name and/or name of individual as it appears on your Federal DEA controlled substance registration certificate. License Type. For example: Retail pharmacy,practitioner, distributor, Hospital/clinic Name of the person that signed the original application for the registration and/or the most recent renewal submitted to the DEA Name of the person authorized to execute (sign) the DEA 222 form We reserve the right to ask for a Power of Attorney at any time another person executes a DEA Form 222 in your behalf

8 Are you currently under investigation by the DEA, if yes please provide information Have you been investigated or inspected by the DEA in the last 5 year? If yes, please provide information of investigation and the corrective Actions taken Have you or your company or business ever had a controlled substance Registration denies, revoked or suspended for cause? If yes, attach a Synopsis of this actionon a separate sheet of paper For controlled substance sales, you MUST indicate below all types of customers that purchase controlled substances from your business. Please circle yes or no and provide notes if needed. Dispensing to End User YES NO Diet Clinics YES NO Emergency clinics YES NO Government Agencies YES NO Hospice Patients YES NO Hospice Pharmacies YES NO Hospitals YES NO Internet Pharmacies YES NO Mail Order YES NO Nursing Homes/Assisted Living YES NO Pain Clinics YES NO Pharmacies YES NO Physicians YES NO Wholesaler Distributors YES NO OTHER Please indicate YES NO

9 Please attach a copy of your policy and procedure plan for handling and dispensing controlled substances. We thank you for furnishing the information above and for attaching the supporting documentation as requested. If you have questions, please contact Mirow Biglari Phone number (818) or fax (818) or Fairfax@fairfaxpharmaceutical.com Your signature is required below I certify penalty of perjury that the forgoing information is true and correct. I also agree to contact Fairfax Pharmaceutical Wholesaler Inc. if there is any change in the regulatory status of this business such as a change in licensure or ownership. Signature of person identified in Section B. question: Date: Print Name: