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Password must contain the following:
12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character
BUSINESS INFORMATION
All fields with an * asterisk are required and must be completed to submit the application.
Company Legal Name
Name company is registered with the state
DBA Name (Doing Business As)
Business Name on the building
Business Phone
ex: 111-111-1111
Business Fax
ex: 111-111-1111
Business Email
Ex: myemail@InComm.com
BUSINESS ADDRESS INFORMATION
Address 1
ex: 123 SW Main Street
Address 2
ex: Suite, Building
City
State
Zip Code
Is the Billing Address different from the Company Address?
Yes
No
BUSINESS BILLING INFORMATION
Billing Address Line 1
ex: 123 SW Main Street
Billing Address Line 2
ex: Suite, Building
Billing City
Billing State
Billing Zip Code
Billing Phone Number
ex: 111-11-1111
PRINCIPAL INFORMATION
Note: All Principal information is required and should include the business owner's personal information only
Principal First Name
Principal Last Name
Principal Email
Ex: myemail@InComm.com
Principal Phone
ex: 111-111-1111
Business Owner Title
Please select...
President
Vice President
Treasurer
Chief Financial Officer
Other
If "Other" Title is selected. Enter other title here
Home Address 1
(Home Address is REQUIRED as part of the background check on the Principal applying.)
ex: 123 SW Main Street
Home Address 2
ex: Suite; Building
City
State
Zip Code
COMPANY INFORMATION
Company Type
Please select...
Sole Proprietor
C-Corporation
S-Corporation
Limited Liability Company
Limited Liability Partnership
Partnership
Other
Limited Liability Type
C = C corporation
S = S corporation
P = partnership
If "Other" is selected, enter other company type here
STATE ID/ TAX BUSINESS REGISTRATION INFORMATION
Type of Business
Please select...
Pharmacy
Grocery
Both
Federal ID/EID
NPI Number
Dun & Bradstreet #
If applicable
SIC
If applicable
Number of year(s) in business
Do you have multiple locations under this one legal business entity
?
Yes
No
How many locations do you have?
What percentage % of your inventory is Domestic? (UPC11)
What percentage % of your inventory is International? (EAN - GTIN)
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