Reason for Requesting Credit: c New c Renew c Increase Credit Line Sought ___________________
Valley Customer Application Process We are delighted to serve your healthcare distribution needs. Our desire is to make your onboarding process as seamless as possible. Step 1: Complete and sign the subsequent forms. Step 2: Please include: • DEA License
• State License • Sellers Permit
If this is a newly acquired business, please provide a copy of power of attorney.
Step 3: Do you currently purchase or have plans to purchase controlled substances from Valley Wholesale Drug? c Yes c No
Do you have a CSOS certificate?
c
Yes
c
No
Step 4: Submit completed documents.
Fax: 800.228.0131
Email:
[email protected]
Mail: 1401 W. Fremont Street, Stockton, CA 95203
For Valley Wholesale Drug Use Only Credit Limit Approved
Reviewed by
c New ownership
c Existing ownership
Date
Shipping Position: c Primary c Secondary Shipping Per Day: c Once Shipping Days:
02082016
c Twice
c Monday c Tuesday c Wednesday c Thursday c Friday c Saturday
1
Phone: 800.247.6255 | Website: vwdco.com
Reason for Requesting Credit: c New c Renew c Increase Credit Line Sought ___________________
Account Application Company Information Company Legal Name Doing Business As
Has your pharmacy every operated under a different name? c Yes
c No
If yes, what name(s)? Phone Number
Fax Number
Shipping Address
City, State, Zip
Billing Address
City, State, Zip
Website
Store Hours
Company Type: c Corporation
c Partnership
c Proprietorship
c LLC
c PLC
Type of Business
Year Business Established
Number of Employees
Annual Sales
Federal Tax ID
State of Incorporation
Owner or Corporate Officer Information 1. Name
Title
Home Address
City, State, Zip
Phone Number
Social Security Number
Number of Years or Months as Owner
Percentage of Ownership
2. Name
Title
Home Address
City, State, Zip
Phone Number
Social Security Number
Number of Years or Months as Owner
Percentage of Ownership
Bank Contact Person
Bank Contact Phone Number
Bank Address
City, State, Zip
Checking Account Number
Savings Account Number
1. Company Name
Contact Name
Phone Number
Account Number
2. Company Name
Contact Name
Phone Number
Account Number
3. Company Name
Contact Name
Phone Number
Account Number
Bank References Information Bank Name
Trade Credit References
10192015
2
Phone: 800.247.6255 | Website: vwdco.com
Account Application Continued Company or Personal Assets Cash
Land
Building
Other Property
Accounts Receivable
Leasehold Improvement
Company or Personal Liabilities Mortgage
Rent
Accounts Payable
Long Term Debt
Notes Payable
Terms and Conditions 1.
2.
Payment a. Payment shall be made by the Customer within 10 days from date of statement. Statements are sent out twice a month. One on the first of every month which reflects purchases made from the 16th through the end of the month of the previous month. Second on the 16th of every month which reflects purchases made from the 1st through the 15th of the same month. b. Legal costs for recovery of any overdue amounts will be recoverable as debt due by the customer. Deductions a. Do not deduct off invoice or statement for returns. b. Do not deduct off invoice or statement for price discrepancies.
We prefer that you do not take deductions prior to receiving credit because it will complicate our bookkeeping. Please call customer service to resolve the issue prior to taking the deduction. Acknowledgement of Credit Account Terms and Conditions The above information is warranted to be true and complete. We hereby authorize you to verify and collect information on us, including but not limited to bank references, trade credit references, consumer and/or commercial credit reports. We agree to pay all costs of collection and litigation on this account in accordance with the laws of the Creditor’s State of Incorporation should such action be necessary due to non-payment. We authorize the creditor to obtain credit reports on the proprietors, partners or principals. Should a credit availability be granted by the creditor, all decisions with respect to the extension or continuation shall be in the sole discretion of the creditor. The creditor may terminate any credit availability within its sole discretion. Any disputes or controversy arising from this agreement will be resolved by arbitration by the American Arbitration Association at Orange County, California. The language of the arbitration shall be English. The number of arbitrators shall be one. The parties agree the American Arbitration Association’s expedited rules shall apply and they waive all rights to any hearing requiring witness protection. The arbitrator shall issue an award based upon the written documentary evidence supplied by the parties. The arbitrator’s award shall be binding and final. The losing party shall pay all arbitration expenses, including the attorney’s fees.
1. Printed Name
Title
Signature 2. Printed Name
Date Title
Signature 3. Printed Name
Date Title
Signature
Date
Personal Guarantee The undersigned for consideration do hereby individually and personally guarantee the full and prompt payment of all indebtedness heretofore or hereafter incurred by the above business. This guarantee shall not be affected by the amount of credit extended or any change in the form of said indebtedness. Notice of the acceptance of this guarantee, extension of credit, modification in terms of payment and any right or demand to proceed against the principal debtor is hereby waived. This guarantee may only be revoked by written notice which shall be sent to the creditor’s credit office by certified mail. Any revocation does not revoke the obligation of the guarantors to provide payment for indebtedness incurred prior to the revocation. I authorize the seller and their assigns to obtain consumer credit reports and to contact my references as necessary. As a guarantor, I am also bounded by the above arbitration clause.
1. Guarantor’s Name
Title
Signature 2. Guarantor’s Name
Date Title
Signature 10202015
Date 3
Phone: 800.247.6255 | Website: vwdco.com
Customer Profile Business and Professions Code Requirements The California State Board of Pharmacy Law Business and Professions code section 4059.5 states the following: a. Except as otherwise provided in this chapter, dangerous drugs or dangerous devices may only be ordered by an entity licensed by the board and shall be delivered to the licensed premises and signed for and received by a pharmacist. Where a licensee is permitted to operate through a designated representative, the designated representative may sign for and receive the delivery. b. A dangerous drug or dangerous device transferred, sold, or delivered to a person within this state shall be transferred, sold, or delivered only to an entity licensed by the board, to a manufacturer, or to an ultimate used or the ultimate user’s agent. PHARMACY TECHNICIANS AND OTHER PHARMACY EMPLOYEES ARE NOT PERMITTED TO SIGN FOR ANY PRESCRIPTION OR CONTROL DRUG ORDERS. While we understand and appreciate that this may be an inconvenience for you, we ask that you please cooperate with the delivery drivers, and assist him or her in making timely deliveries by having your pharmacist sign for your delivery promptly. By working together, we can both stay compliant with the Business and Professions Code requirements. Should you have any questions, feel free to contact Valley Wholesale Drug or the State Board of Pharmacy.
Designated Licensed Pharmacist 1. First Name
MI
Title
Last Name
Pharmacist License Number
Signature 2. First Name
MI
Title
Last Name
Pharmacist License Number
Signature 3. First Name
MI
Title
Last Name
Pharmacist License Number
Signature 4. First Name
MI
Title
Last Name
Pharmacist License Number
Signature Attach additional paper if needed. Traceability - Drug Supply Chain Security Act (DSCSA) Contact Person Responsible for DSCSA Activities Phone
Email
DUNS Number
Title
Signature
02082016
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Phone: 800.247.6255 | Website: vwdco.com
Customer Profile Continued Licenses Has pharmacy, owner or staff, ever had a DEA registration or state license suspended, revoked or denied? c Yes c No If yes, please explain Has any owner ever been convicted of a drug related felony? c Yes c No If yes, please explain Date of Last Inspection
Inspector’s Name
Please attach a copy of the last inspection report or list pertinent findings if the point of contact will provide.
Other Licenses Does your pharmacy maintain a pharmaceutical distributor / wholesaler license? c Yes c No If yes, please explain Provide details of any other applicable licenses and associated numbers (ie: out of state wholesaler, mail order, etc.)
Pharmacy Activities Is the pharmacy a closed door pharmacy? c Yes c No Is your pharmacy affiliated through ownership or legal agreements with any online pharmacies or internet websites? (not including VIPPS pharmacy websites, the use of the internet to communicate with prescribers or approved electronic prescribing applications for controlled substances). c Yes c No If yes, is the pharmacy registered with the DEA as an online pharmacy? c Yes c No Estimate the percentage of prescriptions received through online activities, either through affiliation with online pharmacies or websites or through direct activity as an “online pharmacy.”
%
Please provide the following information regarding online pharmacy affiliations: (attach additional sheets as necessary) Name URL
Phone
Do you distribute or warehouse pharmaceutical product to any pharmacy not under your ownership? c Yes c No If yes, please explain How many compounding prescriptions does pharmacy fill on average?
Daily
Monthly
Does the pharmacy fill any control prescriptions for out of state patients? c Yes c No If yes, please describe precautions taken (driver’s license verification, etc.)
Is the respondent aware of any state regulations and/or restrictions regarding controls to filling out-of-state prescriptions? c Yes c No If yes, please explain How does your pharmacy receive payment for products and in what approximate revenue percentage. % Insurance
% Medicare/Medicaid
% Cash, Credit or Debit Card
% Other
If other, please provide details 10202015
5
Phone: 800.247.6255 | Website: vwdco.com
Customer Profile Continued Pharmacy Activities - continued Does your pharmacy service nursing homes, long term care facilities, hospice or other inpatient facilities? If so, what is approximate percentage? % Nursing Home
% LTCF
% Hospice
% Other
If other, please provide details Are you approved to dispense Transdermal Fentanyl Patches (TRIF contract)? c Yes c No Do you service/accept Medicaid/Medical patients? c Yes c No Please provide copies of service agreements.
Drug Control Information How does your pharmacy receive controlled prescriptions and in what approximate percentage. % Electronic
% Fax
% Mail Order
% Phone
% Walk In
If electronic prescriptions are received, have the electronic applications been certified by a third party within the last two years? c Yes c No If yes, please provide details What percentage of controlled items are dispensed for cash payment?
%
What is your average number of controlled substance prescriptions per day? What percentage of your purchases from VWDCO will be controlled substances?
%
Do you dispense large amounts of any controlled item? c Yes c No If yes, please provide product(s)
Do you know your doctors and their prescribing habits? c Yes c No Provide details Please list other distributors from which you purchase controlled substances.
10202015
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Phone: 800.247.6255 | Website: vwdco.com
Customer Profile Continued Pain Management Do you service identifiable pain management or doctors? c Yes c No Doctor/Clinic Name
Prescriber Name
Address
City, State, Zip
Prescriber DEA
Length of Time At Location
Attach additional paper if needed. What is your inventory policy for all controlled items?
How often is your stock assessed? What are the procedures for filling a prescription for a new patient from an unknown physician? Do you feel comfortable with the prescribing practices of the physician? c Yes c No If no, please explain Are you a registered member of the Prescription Drug Monitoring Program (PDMP)? c Yes c No If no, please explain
To sign up, please visit pmp.doj.ca.gov/pmpreg/registrationtype_input.action and click ‘Pharmacist’ to initiate the registration process.
Are you planning on registering? c Yes c No If yes, when
.
If no, please explain
Pharmacy Description and Locale Describe pharmacy premises, including front and back exteriors, behind counter and in front of counter.
Is pharmacy located within medical center? c Yes c No Is pharmacy located within a strip mall? c Yes c No Are there hospitals, physician offices or clinics located in the vicinity of the pharmacy? c Yes c No 10202015
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Phone: 800.247.6255 | Website: vwdco.com
Customer Profile Continued Compliance and Agreement (“Customer”) agrees that it will abide by all applicable laws, rules and regulations in the states into which it dispenses controlled substances and the states in which it is licensed. Further, Customer agrees that it will not dispense controlled substances if it suspects that a prescription is not issued for a legitimate medical purpose or in the normal course of professional practice. In addition, Customer agrees that it understands that Valley Wholesale is required by DEA regulations to report to the local DEA Diversion field office any instances of suspicious orders of controlled substances pursuant to DEA guidelines. To this end, Customer will provide to Valley Wholesale any information regarding its distribution of controlled substances which Valley Wholesale may need to evaluate compliance with DEA regulations. Valley Wholesale reserves the right in all cases to limit or eliminate any sales of controlled substances to customers in any situation which it determines in its sole discretion pose issues or questions of proper usage and/or adequate legal compliance by the Customer. Customer agrees to monitor and be alert to the proper usage of controlled drugs dispensed by it, and to exercise due diligence to ensure the legal compliance by its prescribers and patients with applicable and regulatory guidelines. Customer is expected to exercise its professional knowledge and expertise to keep current on all such legal and regulatory guidelines. Customer acknowledges that Valley Wholesale may provide a copy of this agreement to the DEA, other federal regulatory agencies, state regulatory agencies, or state licensing boards when determined to be appropriate. Customer agrees that failure to comply with this Agreement may result in the termination of the relationship between Valley Wholesale and Customer, in whole or in part, notwithstanding any other agreements to the contrary. Please certify that you, under penalty of perjury, operate within the laws and rules of the governing state and federal DEA as a licensed retail pharmacy and/or wholesale distributor of pharmaceutical products and that the information included is true and correct. Agreed to by a duly authorized officer, partner or principal of Customer. Signature
Date
Full Name (print)
10202015
Title
8
Phone: 800.247.6255 | Website: vwdco.com