Bayer U.S. LLC - Animal Health

New Account Application
* - indicates required field

Business Information
Company Name *  
Doing Business As (DBA)

Billing Address
Billing Street Address *  
City *  
State *  
ZIP Code *  
PO Box
County *  
Phone *  
Fax *  
Contact Name
Email
Shipping Address
Business Name
Shipping Street Address *  
City *  
State *  
ZIP Code *  
County *  
Phone *  
Fax
Contact Name
Email
If multiple ship-to locations, attach file
{.doc,.docx,.xls,.xlsx,.pdf,.png,.jpg,.txt}
 

Date Company Opened
Legal Structure *  
If Legal Structure is Other,
then specify
Type of Practice *  
If Type of Practice is Other,
then specify
Company Website / URL

Was this business purchased from a
previous owner or doctor?
If yes, please provide the following:
Purchase Date Name Account Number

Sales Tax Exempt *  
If exempt, a copy of your tax exempt certificate is required {.doc,.docx,.xls,.xlsx,.pdf,.png,.jpg,.txt}  

Financially Responsible Person/Organization
Name *  
Title *  
Company *  
Address *  
City *  
County *  
State *  
ZIP Code *  
Phone *  
Fax
E-Mail

Veterinarian Information
Title (please select all that apply) Name (First, MI, Last) State License Number Expiration Date {MM/DD/YYYY}
*   *   *   *   *  
 

 

 
Name of Affiliated Clinic
Phone
Fax
Email
By signing below you agree to be responsible for the oversight, ordering and use of Bayer Animal Health (BAH) FDA prescription products for the animals cared for by this account. Further, you acknowledge and represent that you have and maintain all licenses and permits required by state and federal law. Please note: Products purchased for this account will be shipped to the attention of the primary veterinarian at this account. Please provide Bayer prompt notice should you no longer be responsible for dispensing at this facility.
Veterinary Name (Signature) *  
Veterinary Name (Printed) *  
Title *  
Date *