A1108			Akorn, Inc.  		Revision:  02-08 Supersedes: 02-06
Akorn, Inc. 2500 Millbrook Drive Buffalo Grove, IL 60089  Fax: 800-943-3694

Customer Account and Credit Application
1.	DEA License number and state license number (required)
2.	DEA and state license expiration date (required)
3.	Bill to name and address – city, state, zip, county, phone, fax, purchasing contract name
4.	Ship to name and address – city, state, zip, county, email address, acct. payable contract name
Important!  
Attach copies of required forms (DEA certificate and or state license and tax empty form.
5.	Membership:  If member of GPO or Buying Group, please identify membership.  Do you wish to have your Akorn purchases billed to your membership?  Yes or No
6.	Type of business:  corporation, partnership, solo proprietor (social security number, other (specify)
7.	Define operation (check only one):  Hospital or hospital pharmacy, surgery center or cataract surgeon, EMS (Emergency medical services), retail chain or grocery, retain pharmacy, research facility or university, industrial (poison control products only), urologists, rheumatologist, distributor (if distribution, do you export ?) Yes or No (please specify, retinal specialist, ophthalmologists (not a retinal specialist) optometrist
8.	Principals:	Name, position, home address, phone number
9.	Bank Preference – bank name, account number, address, phone
10.	Trade References (Minimum of three) – name, address, phone number and fax number.
11.	Credit Limit Requested: Credit limited needed, Need monthly statement?  Yes or no.  The undersigned agrees to pay any balance after thirty (30) days and all actual attorney fees and costs of collection:  personally guarantees all payments and unconditionally waives the right to any amount paid pursuant to this provision.  The undersigned hereby consents to the confirmation by company, and its divisions of the information contained herein and authorize Akorn Inc. to contact the undersigned bank and supplies listed herein and obtain the necessary credit reports.  Terms of sales have been fully explained and I understand that if an account is established, my credit line is subject to periodic review.  Also, shipments may be held if my account is delinquent or exceeds my established line of credit.  The undersigned authorizes company to take appropriate measure in verify the credit of the undersigned and releases company form any obligation while researching information.
12.	Signature:  Your signature, title, date

Office Use only:  credit limit (amount), date approved, signature, CR number, Terms, Account number, sales rep, and discount
Ref:  SOPxA1108-BG104

Sample information: 
 Below is what was used as a sample. 
1.	RM0339831
2.	1-31-2009
3.	CA Department of Health, 221 Nowhere Lane, Noplace, CA, 22211, 510-123-4567, 510-123-5476, Dick Tracy
4.	McKesson Specialty Distribution, 4853 Crumpler Road, Memphis, TN,38141, dick.tracy@ca.us.gov, Betty Boop
5.	n-a
6.	Under other – state gov’t
7.	Under other – state gov’t
8.	Daffy Duck, vaccine manager, 510-222-3333.  Donald Duck, Vaccine ordering clerk, 510-222-4444
9.	Anywhere Bank, 0012345678, Gotham City, 510-231-6789
10.	n-a
11.	n-a
12.	n-a

This document can be found on the CDC website at:
http://www.cdc.gov/vaccines/programs/vmbip/downloads/agm/sam-aca-form.rtf