New Customer Setup Information


Note: All Fields are Required

General Information

Organization Name
Address
Business entity type
Company Website
Federal Tax ID
State Tax ID
Affiliated Entities (if any)
Corporate Officers

DEA License #
 I have a DEA license     Not Applicable
DEA License Expiry Date

State License # for Controlled Substance
 I have a State License for Controlled Substance     Not Applicable
State License Controlled Substance Expiry Date
State License # for Warehouse and Distribution
State License Warehouse and Distribution Expiry Date
Primary Contact Name
Primary Contact Title
Phone
Email ID
Eywa Products of Interest


Billing Information

Billing Address
Billing Telephone
Billing Fax
Billing Email
EDI Capability
EDI Contact Information
CSOS Capacity


Shipping Information

Shipping Location(s) Complete Address
Shipping Location(s) Contact Name
Shipping Location(s) Telephone
Shipping Location(s) Fax
Shipping Location(s) Email

DEA License #
 I have a DEA license     Not Applicable
DEA License Expiry Date
Shipping Home State
License #
Shipping Home State
License Expiry Date