McKesson Customer Application

* indicates a required field.

Company

Type of Business

Legal Company Name*

Website Address

Federal Tax ID*

Legal Address (Main Office)*

City*

State*

Zip*

Contact Name (we may call for questions regarding this application)*

Title*

Phone*

Billing / Statement Address (if different than Main Office)

City

State

Zip

Accounts Payable Contact Person*

Accounts Payable Telephone*

Accounts Payable Fax

Accounts Payable Email*

Shipping Information

DBA or Business Trade Name of Account

Estimated Monthly Purchases*

Initial Order*

Existing McKesson Acct#

Ship to Address*

City*

State*

Zip*

Ship to Contact Person*

Ship to Telephone*

Ship to Fax

Ship to Email*

Years in Business*

State Org/Charter ID/License#*

Name of State*

Has applicant, applicant's parent or affiliates ever filed for bankruptcy? If so, please explain.*

Ownership Type

Principal Owner(s) of Stockholder(s)*

% Ownership(s)*

Social Security Number(s)

Controlling Entity

Name of Controlling Entity (if any)

Applicant’s relationship to controlling entity

Phone

Address of Controlling Entity

City

State

Zip

References

Primary Bank/Financial Institution *

Account Number

Contact Name*

Phone*

Primary Supply Provider*

Account Number

Contact Name*

Phone*

Primary Technology Provider*

Account Number

Contact Name*

Phone*

Additional Information Required (If applicable, please attach these document to this application.)

Copy of Resale/Tax Exemption Certificate

Copy of DEA Registration, State Pharmacy License, or Medical License

Copies of 3 most recent and consecutive primary supplier statements

Annual Financial Statements for the past 2 years (including balance sheet, income statement, and cash flow statements)

DEA#

HIN#

Medical License# & Name of State

This section applies to all "MCKESSON MEDICAL-SURGICAL INC., McKesson Medical-Surgical Minnesota Supply Inc., and Moore Medical LLC" accounts only

Invoices are due 30 days from the date of invoice unless otherwise stated. Actual payment terms extended may differ depending on credit approval and are due as printed on the invoice. Please refer to the most recent invoice and statement for actual payment terms. A 1.5% per month service charge (or the maximum amount permissible under applicable law, if lower) will be imposed on all past due balances.

McKesson Account Manager*

Territory ID*

This section applies to all accounts with MCKESSON CORPORATION and its affiliated companies ("McKesson")

Customer agrees to abide by (i) standard terms of sale provided or made available by McKesson and/or shown on McKesson's invoices or statements and (ii) any written agreement or terms of sale with McKesson governing Customer's account. Customer agrees to pay for all purchases, fees and other charges incurred by Customer or an authorized user on any account of Customer, including service charges on past due amounts at the highest rate permitted by law (including purchases shipped and/or billed to a third-party agent on behalf of Customer). Any payment made after the net due date shall result in the loss of any prompt cash payment discount specified on the related invoice or statement and Customer shall pay the gross amount plus any applicable service charges. Without limiting McKesson's other legal rights, McKesson may exercise a right of set-off against amounts due Customer from McKesson Corporation or any of its affiliates. McKesson reserves the right, in its sole discretion, to change a payment term (including imposing cash payment upon delivery), to limit total credit and/or to suspend or discontinue the shipment of any orders to Customer if McKesson concludes that (i) there has been a material adverse change in the Customer's financial condition or payment performance or (ii) Customer has ceased or is likely to cease to meet McKesson's credit requirements.

Customer represents that it is entitled to discounted prices from manufacturers as it has notified McKesson ("Contract Prices"). In consideration of McKesson allowing Customer to purchase products at Contract Prices, Customer represents that McKesson will be paid by the appropriate manufacturer the difference between McKesson's acquisition price and the Contract Price ("Chargeback") and Customer will be liable to McKesson for any unpaid Chargeback if any manufacturer (i) denies a Chargeback for any reason, (ii) makes an assignment for the benefit of creditors, files a petition in bankruptcy, is adjudicated insolvent or bankrupt, or if a receiver or trustee is appointed with respect to a substantial part of its property or a proceeding is begun which will substantially impair its ability to pay Chargebacks or (iii) fails to pay McKesson Chargebacks for any reason other than McKesson's gross negligence.

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating due to race, color, religion, national origin, sex, marital status, age; or because all or part of the Customer's income is from any public assistance program; or the Customer, in good faith, exercises any right under the Consumer Credit Protection Act. The Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580 administers compliance with this law. Customer represents and warrants that Customer has read and understands this form and has reviewed the information provided in its entirety, including responses completed for Customer by a McKesson representative, and that all information is complete and correct. Customer agrees that McKesson will be relying on such information and will notify McKesson of any material changes to such information.

Customer agrees to provide McKesson with financial statements upon request. Customer authorizes McKesson, its employees, representatives, and agents to (i) investigate information provided and Customer's credit, financial and banking records, (ii) obtain Customer's credit bureau report and (iii) share with its affiliates experiential and transactional information regarding Customer and Customer's account. McKesson is authorized to retain information obtained as part of the application process whether or not the requested account and/or credit is granted. Customer agrees to pay all reasonable attorney fees and expenses or cost incurred by McKesson in enforcing its rights to collect amounts due from Customer. This form and any account opened in favor of Customer are subject to credit approval by McKesson.

Name*

Title*

Date*

Signature* (draw with mouse or finger) Clear Signature