Republic form

Republic - Customer Setup Form


MM slash DD slash YYYY
MM slash DD slash YYYY
Billing Address
Shipping Address


INDUSTRY REFERENCES (Check N/A for Credit Card P.O.S. )N/A

Applicant certifies that the information contained herein is true and correct, and further authorizes Republic Pharmaceutical to make any inquiries necessary for verification purposes of the information provided. The Applicant agrees that all credit and sales made shall be subject to the following terms and conditions: (1) Applicant shall pay the full amount of the invoices(s) when due, which is defined to be thirty (30) days from the invoice date unless otherwise agreed to in writing by Republic Pharmaceutical; (2) if payment in full is not received by the due date, in addition to the invoice amount, Applicant may be subject to late fees up to the maximum allowed by law on all unpaid balances, plus costs of collection, including, but not limited to, attorney's fees, court costs, and collection fees that Republic Pharmaceutical may incur in recovering the amount that is owed; (3) Applicant agrees that venue and jurisdiction for any such court action shall be held in Washtenaw County, MI the principal place of business of Republic Pharmaceutical.
I further Certify that I am an officer of Applicant, knowledgeable for the financial condition of Applicant, and that I am empowered and authorized to enter int the aforesaid Agreement on Applicant's behalf.
MM slash DD slash YYYY
Max. file size: 50 MB.