New Customer Application COMPANY NAME: TAX EXEMPT: NON-TAX EXEMPT: Items Required with Application FEDERAL TAX ID: CONTACT NAME: If purchasing Rx Product - State or Federal License/Permit (include with application or send directly to: lsherry@imprimispharma.com) TELEPHONE: If U.S. Sales Tax Exempt - Certificate MUST Be Provided Canadian G.S.T. # E-MAIL: BILLING PREFERENCE (check one): EMAIL ( ) FAX ( ) Canadian P.S.T. # PLEASE PROVIDE EMAIL or FAX #: If you are unable to receive invoices via email or fax, please provide Billing address below: BILLING ADDRESS: City State / Prov. Zip / Postal Code SHIPPING ADDRESS: City State / Prov. Zip / Postal Code A/P Contact and Phone Number: TO MAKE PAYMENTS, VIEW INVOICES OR STATEMENTS ONLINE, PROVIDE EMAIL ADDRESS: NUMBER OF YEARS IN BUSINESS: TYPE OF BUSINESS / DESCRIPTION CORPORATION: PARTNERSHIP: NUMBER OF EMPLOYEES: SOLE-PROPRIETORSHIP: PARENT COMPANY: PHONE # OWNER / PRINCIPAL / GENERAL MGR: PHONE # ESTIMATED MONTHLY CHARGES $ To be elegible for credit, estimated charges must exceed $5,000 per month. YES DO YOU REQUIRE A PO # ON ALL ORDERS? ARE YOU USING ANY CONTRACTS? YES NO If YES, please specify below: NO PREMIER / AMERINET / NOVATION / BROADLANE / HEALTHTRUST PURCHASING GRP / MEDASSETS / OTHE BUSINESS REFERENCES BUSINESS: Type of Business: ADDRESS: CITY / STATE / ZIP: CONTACT NAME: PHONE: BUSINESS: Type of Business: ADDRESS: CITY / STATE / ZIP: CONTACT NAME: PHONE: BUSINESS: Type of Business: ADDRESS: CITY / STATE / ZIP: CONTACT NAME: PHONE: BANK REFERENCE NAME: Branch / City / State / Province: CHECKING ACCOUNT #: CONTACT NAME: TELEPHONE / FAX #: FREIGHT TERMS: PREPAID AND ADDED TO YOUR INVOICE. TERMS CAN ALSO BE FOUND ON OUR INVOICE. ALL PRODUCT IDENTIFIED ON A INVOICE IS BEING SHIPPINED F.O.B. SELLER'S PLACE OF SHIPMENT. ALL RISK OF LOSS SHALL PASS UPON SELLER'S DELIVERY OF THE PRODUCT TO THE CARRIER. I hereby authorize the above credit/bank reference(s) to release any appropriate credit information. I/We agree to pay all debts incurred within the terms of sale. I/We further agree to pay collection costs of past due amounts, including court costs and attorney's fees. Past due amounts are subject to an interest charge of 1 1/2% per month or the highest rate allowable by state law, not to exceed 1 1/2%. If approved for credit, terms of sale are NET 30 days from invoice date. Signature (Printed Name) Title MUST BE SIGNED BY APPLICANT. INDIVIDUAL MUST BE AUTHORIZED TO CONDUCT COMPANY BUSINESS. Please return completed form to: Sales Representative: Laura Sherry Fax number: Email: Telephone: (858) 345-1745 lsherry@imprimispharma.com (858) 704-4022 Date