Download this form - Red Ball Medical Supply

Red Ball Medical Supply, Inc
Application for Credit
Phone 318.424.8393
Fax 855.293.7761
Date _______________________________________
Business Name
Billing Address
Phone Number (
Shipping Address
)
Phone Number
Contact Person
Type of Ownership (
(
)
Contact Person
) Corporation (
If Incorporated - What State
) Partnership (
) Proprietorship (
) Other
Principal Officer
(or Owner)
Title
If Subsidiary - Give Parent Company
Business Name
Phone Number
Address
Contact Person
(
)
References: List only those you have done business with during the last six (6) months.
Company Name
Type of Business
Address
Account Number
Phone Number
(
)
(
)
Phone Number
(
)
Phone Number
(
)
Company Name
Type of Business
Address
Account Number
Phone Number
Company Name
Type of Business
Address
Account Number
Name of Financial Institution
Contact Person
Federal Tax ID #
Applicable Tax Rate - State
% Parish
% City
If Tax Exempt, Please send Exemption Certificate for our files
%
Red Ball Medical Supply, Inc
Phone 318.424.8393
Fax 855.293.7761
The Louisiana State Board of Wholesale Drug Distributors, in accordance with Louisiana State Law
R.S. 37:3461-3482, requires that wholesalers (Red Ball Medical Supply, Inc) distributing “Medical Gas” (Federal
Legend) products must have on file a current copy of one of the following licenses:
1. D.E.A. number (Business or Attending Physician)
Expires
2. Medical Examiners’ License
Expires
3. Dental License
Expires
4. Veterinarian License
Expires
5. State Board of Pharmacy License
Expires
6. Dept of Health & Hospitals License of a Medical
Professional authorized to procure federal legend drugs
Expires
7. EMS or Paramedic license for a safety department or
fire department
Expires
8. Home Health Agency - Medicaid & Medicare number
on their letterhead along with their FDU Permit
Expires
Without this information on file, Red Ball Medical Supply will not be able to provide you with Federal Legend drug
products. Federal Legend products are defined as any drug product that carries a caution label on it stating:
“Federal (USA) law prohibits dispensing without prescription”. Distributors purchasing from Red Ball Medical
Supply, Inc must provide a copy of their Louisiana State Board of Wholesale Drug Distributors License.
We will need a physical copy of your license for our files in order for us to
provide you with any of our medical gases.