New Account Application

    Fax: 718-301-1227 / 646-292-5120

    P.O. BOX 230122

    BROOKLYN , NY 11223

    New AccountUpdate Existing Account

    To ensure no delays in orders Submit a copy of Your RESALE CERTIFICATE Attach Your Latest Financial Statements if requesting Credit ( FAX TO CREDIT DEPT 718-301-1227 )

    Corporate Info

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    PharmacyReligious OnRetailWholesalerBroker

    Bank References

    CHECKINGSAVINGSLINE OF CREDITOTHERAccount#

    Business/trade references

    WE WILL NOT PROCESS IF YOU DO NOT ATTACH YOUR RESALE CERTIFICATE