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Credit Application Please Print this section and Fax to:540-776-2090   Date Account Name: Billing Address: City                                                                         State                                 Postal Code Shipping Address: City                                                                         State                                 Postal Code Telephone Numbers  (            ) Facsimile Number       (            ) Purchasing Contact: (          )                                                   Fax:   (           )   E-Mail Address   Purchase Order Requirements:    Circle One     (Y)    (N) Federal Tax ID: Payables Contact:  (           ) Account Type:  Corporation [ ]    Partnership [ ]   Individual [ ]         Please list the following of all owners & partners: Name Address Title Tax ID (SSN): - - - - - - - - - - - -     CREDIT REFERENCES: (Please list only those references with whom you have made purchases from within the past six (6) months) Name Address Account # Telephone: - - - - - - - - - - - -      Bank References: Name Branch Account # Telephone: - - - - - - - - We hereby authorize VAW to contact the above listed bank and credit references in order to verify the stated information. We understand that VAW's terms are Net 15 days from date of shipment and further understands that a late charge of 1.5% per month may be assessed on the past due invoices. We agree that any invoice left unpaid beyond thirty (30) days is determined to be "Past-Due" and payable upon demand. Print Name:____________________________________________ Print Name:__________________________________________ Signature:_____________________________________________ Signature:_____________________________________________ Title:__________________________________________________ Title:_________________________________________________ PLEASE INCLUDE A COPY OF ANY OF THE FOLLOWING LICENSES WITH APPLICATION: DEA, STATE PHARMACY OR STATE PHYSICIAN 1802 Braeburn Drive Salem, VA 24153   Telephone 540 776-2061  FAX: 540 776-2090