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FAX TO: CUSTOMER APPLICATION

McKesson Corporation and its affiliated companies (collectively referred to as McKesson ) fax to : _____ CUSTOMER APPLICATION (Please print in block letters) CD01-S Business Type: Acute Primary Care Specialty Home Health Extended Long Term Pharmacy Closed Door Internet Mail Order Supplier Government Other_____ Legal Company Name Website Address Federal Tax ID Legal Address (Main Office) City State Zip Contact Name we may call for questions regarding this APPLICATION Title Phone Billing / Statement Address (if different than Main Office)

Customer agrees to pay for all purchases, fees and other charges incurred by Customer or an authorized user on any account of Customer, including service charges on past due amounts at the highest rate permitted by law (including purchases shipped and/or billed to a third-party agent on behalf of Customer).

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  Applications, Customer, Account, Fax to, Customer application

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