LLorens Customers:
 
COMPANY INFORMATION: *Must be completed
Date *  
Name of Company *
Street Address *
City *
State *
ZIP *
Phone *
E-mail Address *
Fax *
Web site *
State Tax ID *
Years Established *
Llorens Sales Representative Name:
SHIPPING ADDRESS: *Must be completed
Name of Company *
Street Address *
City *
State *
Zip Code *
ACCOUNTS PAYABLE INFORMATION: * Must be completed
Contact Person *
Phone *
E-mail *
Fax *
Address *
City *
State *
Zip *
OWNERS' INFORMATION: *Must be completed
Name of Owner *
Address *
Job Title
Phone *
Fax *
E-mail *
LICENSES
State License # *
DEA Registration #

License stated that the company met all requirements of the and rules of the state.
Drug Enforcement Administration License- FOR PRESCRIPTION DRUG ONLY.
CREDIT REFERENCES
Reference 1 *
Phone
Reference 2 *
Phone
Reference 3 *
Phone
DISCLAIMER AND SIGNATURE
By Submitting this application, I, the undersigned, certify that all information on this application is accurate and true to the best of my knowledge. Furthermore, I , the undersigned, give authorization to Llorens Pharmaceutical International Division to check and verify my credit history and bank information for the purpose of determining credit rating and business relationships. Electronic Signature is permitted.
Signature
Print Name
Title
Date