Wholesale Distributor Authorization

This authorization relates to purchases from Smiths Medical ASD, Inc.
PART A – CUSTOMER AND SHIPPING INFORMATION
Please Print or Type:
Facility Name and Account #:______
Contact Name:______E-mail address:______
Company Sold-To Address: ______
City:______State:______Zip:______Telephone:______
Does customer have multiple shipping addresses? *
*If the shipping address is different from the ‘Sold-To’ address, or there is more than one shipping address applicable to these licenses, please include an attachment with additional addresses.
PART B – PRODUCT CATEGORY AND LICENSE INFORMATION
I, the undersigned, am the authorized representative of the above named facility at the above specified ‘Sold-To’ address. In this capacity, I hereby authorize the facility to authorize the below-indicated category(ies) of products and submit the following
referenced license(s) with respect to such orders, with a copy of such license(s) attached to this form.
[Please check appropriate box(es) and complete corresponding license information.]
We wish to order  Prescription Drugs and Medical Devices  Prescription Medical Devices ONLY. License authorizing the above specified address to purchase prescription drugs and/or medical devices is as follows:
State Board of Pharmacy Wholesaler License #______Expiration Date: ______
 We wish to order kits containing Ephedrine Sulfate (a List 1 Chemical): License(s) authorizing the above specified address to purchase kits containing Ephedrine Sulfate is as follows:
DEA License #______Expiration Date: ______
State Controlled Substance License # ______Expiration Date: ______
State controlled substance license is required for certain states. For those states, both the DEA and state license must be provided.
PART C – STATEMENT OF AUTHORITY AND SIGNATURE
I hereby certify that (i) I am the authorized representative for the facility identified above in Part A with respect to the specified address; (ii) that the license information provided is current and accurate and (iii) I understand that failure to provide complete and truthful information may constitute grounds for the vendor to recommend that appropriate authorities bring disciplinary actions against me and/or the facility.
Signature: ______Date: ______
Print Name: ______Print Title: ______

Instructions:

This Authorization is only valid if accompanied by a copy of the license(s) specified in Part B. This Authorization will expire at the time of the expiration of the above-specified license(s) (as applicable to the product ordered). Upon expiration, a new Authorization must be submitted for orders to be processed.

Please complete this form and submit a copy of the appropriate license(s) to Licensing Office by email to or fax to 603-355-8157.

Page 1 of 1 FM-DBNSOP900-01 Rev.000 Effective Date: 22-Nov-13 DBLQCO10544