become a Direct Purchase CustomerInterested in becoming a Direct Purchase Customer? Fill out the form we will be in touch shortly! SHIPPING INFORMATION Pharmacy/Wholesaler/Clinic Name * Pharmacist/Representative in Charge Name * First Name Last Name Purchasing Contact (Person who will be placing orders) * First Name Last Name Email address * Phone number * (###) ### #### Address (no P.O. Box) * Address 1 Address 2 City State/Province Zip/Postal Code Country Office Manager * First Name Last Name DEA License Number Controls * Expiration Date * MM DD YYYY State License Number * Expiration Date * MM DD YYYY Type of Business (check all that apply): * Retail Pharmacy Specialty Pharmacy Wholesale/Distributor Repacker/Relabeler Clinic Long Term Care Facility Other Area of Specialty (check all that apply): Pain Management Dermatology Cardiology Infectious Disease PEdiatric Geriatric Psychiatric Non-Sterile Compounding Sterile Compounding Other BILLING INFORMATION Company Name A.P. Manager (contact person for billing) First Name Last Name Address (billing) Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number (###) ### #### AUTHORIZED PURCHASING AGENT(S) Dear Customer: In order to Comply with 21 CFR1305 and prevent diversion of controlled substances, Salerno Pharma identifies and establishes the authorization status of each person seeking to order a controlled substance and only accept such orders from persons legally authorized to place them. Designations are valid for one year. 1. Agent Name First Name Last Name Title Authorized to Purchase (Specify Schedules): 2. Agent Name First Name Last Name Title Authorized to Purchase (Specify Schedules): 3. Agent Name First Name Last Name Title Authorized to Purchase (Specify Schedules): TERMS AND CONDITIONS Please Read, Sign, and Date the Following Statement In order to induce Salerno Pharma to establish an open account line of credit based on the foregoing application, and in consideration thereof, the undersigned promises to pay Salerno Pharma for monthly purchases in accordance with Salerno Pharma’s terms of sale. If at any time, for any reason, the undersigned is unable to pay for monthly purchases when due, the undersigned agrees to pay, and authorizes Salerno Pharma to bill the undersigned, all past due amounts owing in addition to interest thereon, computed at the rate of ten percent (10%) or the highest legal rate. In the event it becomes necessary for Salerno Pharma to incur collection costs or institute suit to collect any amount due under this agreement, or any portion thereof, the undersigned promises to pay all such collection costs and costs of suit, charges, and expenses, including reasonable attorney's fees. This Agreement shall be governed by and construed in accordance with the laws of the State of Oklahoma without regard to the conflict of laws provisions thereof. Further, the undersigned unconditionally and irrevocably consents and submits to personal jurisdiction and venue in the courts of Tulsa, Oklahoma in any dispute arising out of this agreement or any product ordered in connection with this agreement. Applicant further acknowledges that credit privileges, if granted, may be withdrawn by Salerno Pharma at any time. Salerno Pharma will bill shipping charges on all invoices and all shipments will be paid by the undersigned to Salerno Pharma at the time of billing. Shipping charges can be increased from time to time without notice to payee on any products ordered. RETURN POLICY: RETURNS AND EXCHANGES OF OTC PRODUCTS ONLY WILL BE PROVIDED AT THE SOLE DISCRETION OF SALERNO PHARMA ALL PRODUCTS LABELED RX ARE SOLD AS‐IS AND HAVE NO RETURN POLICY UNLESS RECALLED. OTC PRODUCTS ISSUED WITHIN 30 DAYS OF PURCHASE ARE THE ONLY ITEMS ELIGIBLE TO BE CONSIDERED FOR RETURN OR EXCHANGE. ALL RETURNS WILL BE ISSUED A CREDIT LESS 25% RESTOCKING FEE AND SHIPPING COST. NO REFUNDS. ORDER AGREEMENT This Authorization Agreement (this "Agreement") is entered into between Salerno Pharma and the undersigned (hereinafter the "Applicant") as of the date executed below. Applicant certifies that the above information is true and correct. Applicant agrees (1) that all invoices must be paid 30 days from date on invoice, (2) that any invoiced amounts not paid within (15) fifteen days after the date due shall bear interest at the maximum non usurious rate permitted by law (currently 10% per annum) from the date due until paid, (3) Claims arising from invoices must be made within seven working days, (4) to pay any and all costs of collection (including without limitation reasonable attorney’s fees) incurred by Salerno Pharma in collecting any overdue account, and (5) that applicant is authorizing Salerno Pharma, to make inquiries into the banking and business/trade references that you have supplied. (6) This Agreement shall be governed by and construed in accordance with the laws of the State of Oklahoma without regard to the conflict of laws provisions thereof. Applicant unconditionally and irrevocably consents and submits to personal jurisdiction and venue in the courts of Los Angeles, California in any dispute arising out of this agreement or any product ordered in connection with this agreement. Applicant further acknowledges that credit privileges, if granted, may be withdrawn at any time. Shipping charges are billed to all invoices and all shipments will be paid by Applicant at time of billing. Shipping charges can be increased from time to time without notice to payee on any of the products (shipping charges for all Salerno Pharma products). I have read and agree to the Terms and Conditions, and Order Agreement * Yes, I understand Date MM DD YYYY Typing your name as a signature First Name Last Name Title Terms of Service * My signature signifies an understanding of the aforementioned agreement LICENSING in order to complete the set up of your account, this form must be signed, accompanied by your facility's DEA License and Pharmacy/Wholesale/Clinic License. Please Note: The DEA license must reflect the shipping address of the medical facility. For Questions, please email at customer.service@salernopharma.com Thank you!
