HyGen Retail Application

Company Name

DBA

Business Type

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Tax ID

Please Check

If the Billing address and Shipping address are the same

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

Online Access Email

Title space Name

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Contact Information

Contact Person for Purchasing

Name

Phone

Phone Extension

Please write your Phone Extension if available

Contact Person for Accounts Payable:

Name

First

Middle

Last

Phone

Phone Extension

Please write your Phone Extension if available

Email

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Trade References:

Primary Vendor:

GPO Membership:

Other Vendor:

HIN:

GLN:

Phone

Information

Company Name

Contact Person

AC

Fax

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Primary Bank Information

Bank Name

Officer's Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

Full Width Inline Paragraph

I hereby certify that the above information is true and correct. The information included in this application shall be used by HyGen Pharmaceuticals, Inc. to determine the amount of credit that can be extended to the above named company. I understand that HyGen Pharmaceuticals, Inc. may utilize other sources of credit, which it deems necessary in determining the credit status. I hereby authorize the bank & trade references to release the needed information listed above and also certify that I am authorized to execute this agreement.

Printed Name (Owner/Officer)

Title

Signature

Clear Signature

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Date

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Terms and Conditions

Payments and Credits:

• Customer agrees to pay HyGen Pharmaceuticals, Inc. (“HyGen”):

Select your preferred payment term for Generics:

10 EOM
Net 30

Note: Brand items are payable at Net 7 with approved credit, unless otherwise agreed in writing.

• Payments by check should be made payable to: HyGen Pharmaceuticals, Inc.

• HyGen shall charge Customer a $30 fee for any bounced check or ACH Transaction rejected due to nonsufficient funds.

• Customer shall pre-pay for orders if paying by credit card. HyGen accepts MasterCard, Visa, and American Express at the time of shipping.

• Customer shall pay HyGen in accordance to the terms reflected on the invoice. Customer shall pay HyGen interest at the rate of 1.5% per month on all amounts past due.

• HyGen shall credit Customer’s payment to the oldest invoice or statement unless Customer’s remittance
document reflects the invoice being paid or the payment exactly matches a specific invoice or statement
amount.

• Credits for returned goods are subject to the most current version of HyGen’s Returned Goods Policy.

Shipping:

• HyGen provides free ground shipping on all generic orders greater than $100.00.

• Bulk quantities, hazardous items, liquids, suspensions & inhalers are shipped via Ground only.

• Any damage, product shortage, or other discrepancy must be notified to HyGen within one business
day of delivery to be eligible for credit.

Governing Law:

• This Agreement shall be governed by the Laws of the State of Washington. The Parties hereby
irrevocably submit to the exclusive jurisdiction of any federal or state court located within the County of
King, State of Washington over any dispute arising out of or relating to this Agreement or any of the
transactions contemplated hereby and agree that all claims in respect of such dispute or any suit, action
proceeding related thereto may be heard and determined in such courts.

Personal Guarantee:

• The undersigned personally guarantees the prompt and full performance of all obligations due and owing
by Customer to HyGen under this and/or any other agreement with HyGen. The undersigned waives
presentment, demand, protest, notice of protest, notice of dishonor and any and all other notices or
demands of whatever character to which the undersigned might otherwise be entitled. The undersigned
further consent to any extension granted by HyGen and waives notice thereof. If more than one guarantor,
the obligation of each shall be joint and several. Termination of this guarantee must be in writing, signed
by HyGen and undersigned, and in such event, shall only apply as to future obligations.

• In the event of default in any payment or other obligation to HyGen, Customer agrees to reimburse HyGen for any and all attorney’s fees, court and other costs and expenses reasonably incurred in collecting or enforcing these Terms and Conditions.

I hereby acknowledge and accept the Terms and Conditions described above and agree that they shall apply exclusively to all dealings between our companies.

Full Name

First

Middle

Last

Title

Signature

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Date

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ACH Payment Authorization Form

Customer Name

Customer Account #

Schedule your payment to be automatically deducted from your checking or savings account. To get started, complete and sign this form and attach a voided check! ACH Payments Will Make Your Life Easier:

• It’s convenient (saving you time and postage)

• Your payment is always on time (even if you’re out of town), eliminating late charges Here’s How ACH Payments Work:

You authorize monthly scheduled charges to your checking or savings account.

You will be charged the amount indicated below each billing period.

A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior notification will be provided unless the date

Agreement Statement:

"I am authorize HyGen Pharmaceuticals Inc. to charge my bank account indicated below at 10 EOM for generic purchases and at Net 7 for brand purchases, with approved credit, unless other terms have been mutually agreed upon in writing."

Please check the Agreement :

I agree to the terms and conditions stated above.

Please complete the information below:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

The check image below provide guidance on the information

Account Type

Checking
Saving

Name on Account

First

Middle

Last

Bank Account Number

Bank Routing Number

Bank Name

Bank City/State

Signature

Clear Signature

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Date

Authorization Text

Customer understands that this authorization will remain in effect until Customer cancels it in writing, and Customer agrees to notify HyGen Pharmaceuticals, Inc. in writing of any changes in payment account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, Customer understands that the payment may be executed on the next business day. Customer understands that because this is an electronic transaction, these funds may be withdrawn from Customer’s account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that HyGen Pharmaceuticals, Inc. may at its discretion attempt to process the charge again within 7 days, and agree to an additional $30/- charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. Customer acknowledges that the origination of ACH transactions to Customer’s account must comply with the provisions of U.S. law. Customer agrees not to dispute this ACH payment with Customer’s bank so long as the transactions correspond to the terms indicated in this authorization form.

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Returned Goods Policy

All returns must be authorized in advance by contacting Customer Service and obtaining written
authorization.
• A 20% restocking fee will be assessed on all returned goods, with the exception of returns due to intransit damage or any discrepancy caused by HyGen.
• If the removal of price stickers damages the product package, the product is ineligible for credit and will
be destroyed.
• Products whose labels have been altered, defaced or damaged as deemed by HyGen Pharmaceuticals,
Inc. are not eligible for credit.
• No returns will be accepted on cold chain items, controlled substances, items which have been special
ordered for Customer, or items which are otherwise indicated as non-returnable.
• HyGen reserves the right to destroy products that are sent without prior authorization. Credit will not be
issued for such items.
• HyGen reserves the right to refuse bulk returns, returns from inactive accounts, accounts with overdue
balances, or accounts in the process of closing
• HyGen reserves the right to refuse any and all returns from Customer if HyGen suspects the goods may
be counterfeit, adulterated, unsaleable, outdated, or otherwise not in compliance with the Returned
Goods Policy, or if Customer has previously attempted to return such goods to HyGen.
• Restocking, handling, and return freight charges may be deducted from return credit at HyGen’s
discretion.
• Allow one to two weeks processing time for credit memos on authorized returns. Please do not deduct
any amounts from your payment related to the returned product before receiving a credit memo.

I Accept the Returned Goods Policy

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California POD Signature

Dear Pharmacy Manager or Pharmacist in Charge,
The California State Board of Pharmacy Law Business and Professions code section 4059.5 states the following:
(a) Except as otherwise provided in this chapter, dangerous drugs or dangerous devices may only be ordered by an entity licensed by the board and shall be delivered to the licensed premises and signed for and received by a pharmacist. Where a licensee is permitted to operate through a designated representative, the designated representative may sign for and receive the delivery.

(b) A dangerous drug or dangerous device transferred, sold, or delivered to a person within this state shall be transferred, sold, or delivered only to an entity licensed by the board, to a manufacturer, or to an ultimate user or the ultimate user's agent.

PHARMACY TECHNICIANS AND OTHER PHARMACY EMPLOYEES ARE NOT PERMITTED TO SIGN FOR ANY PRESCRIPTION OR CONTROLLED SUBSTANCE DRUG ORDERS.

While we understand and appreciate this may take additional time, this is a compliance requirement, so we ask that you please cooperate with the delivery requirements and assist us in remaining compliant by having your pharmacist receive and sign for your delivery.

Please fill in the lines below of the designated licensed pharmacist who is authorized to sign for deliveries of prescription and control drugs. Only these representatives may sign for deliveries from HyGen Pharmaceuticals.

DESIGNATED LICENSED PHARMACIST

Please write at least 3 DESIGNATED LICENSED PHARMACIST

Name

First

Middle

Last

Title

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Are you a WA Customer Only

YES
NO

Resale Certificate (WA Customers Only)

Please Attche your resale certificate along with your pharmacy license and other documents.

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Prescription Drug Exemption Certificate
(WA Customers Only)

Name of Purchaser

Address of Purchaser

Address Line 1

Address Line 2

City

State

Zip Code

Certification Agreement

I hereby certify that I am a registered Washington taxpayer and agree to the above conditions.

Filled out the space using the Bottom fields."

Filled out the space on top here

Description of drugs and other substances to be purchased:

Checkmark if the certificate is for a single purchase or continuing purchases

Single Purchase
Blanket Certificate

Authorized Agent or Purchaser:

Name

First

Middle

Last

Signature

Clear Signature

Date / Time

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Shipping Address

Contact Information

Contact Person for Accounts Payable:

Trade References:

Information

Primary Bank Information

Terms and Conditions

ACH Payment Authorization Form

Please complete the information below:

Returned Goods Policy

California POD Signature

COMPANY INFORMATION

DESIGNATED LICENSED PHARMACIST

Resale Certificate (WA Customers Only)

Prescription Drug Exemption Certificate (WA Customers Only)

Authorized Agent or Purchaser:

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Prescription Drug Exemption Certificate
(WA Customers Only)