8635 154TH AVE NE Redmond, WA 98052 Phone: 877-630-9198 Fax: 425-451-8964 Web: www.HyGenPharma.com Vendor Application Manufacturer – Checklist Thank you for choosing to do business with HyGen Pharmaceuticals, Inc. Please take a few minutes to fill out and fax or scan and email over the following items. Description Completed & Signed New Vendor Application Form – Required Completely filled out. Completed Vendor Electronic Payment Form – Required Copy of Resident State Wholesale License – Required Copy of Washington State Wholesale License – Required Copy of Federal DEA registration (if applicable) Copy of Resident State Controlled Substance License (if applicable) Copy of Most Recent Facility Inspection Reports (if applicable) Copy of VAWD Certificate (if applicable) List of Other State(s) of Licensure including Registration/Permit Numbers Phone: 877-630-9198 Fax: 425-451-8964 Web: www.HyGenPharma.com 8635 154TH AVE NE Redmond, WA 98052 New Vendor Application Form Company Information Legal Company Name: DBA: Year established: Corporation Ownership Type (Check One): Partnership Sole Proprietorship LLC Other: State of incorporation (if LLC or Corporation): Shipping Address: Billing Address: Office Phone: Toll Free: Fax: Remittance Address: Accounting Contact: Name: E-mail: Phone: Fax: Sales Contact: Name: E-mail: Phone: Fax: Company Contact & Title: Email: Warehouse Contact: E-mail: State Wholesale License #: Exp. Date: Federal DEA Lic#: Exp. Date: WA Out of State Wholesale License #: Federal Tax ID #: Exp. Date: Dunn & Bradstreet# Please list all owners with 10% or more ownership Terms: Credit Limit: HyGen Cust #: 8635 154TH AVE NE Redmond, WA 98052 Phone: 877-630-9198 Fax: 425-451-8964 Web: www.HyGenPharma.com Licensing When was the last inspection by the State Board of Pharmacy? Were any deficiencies noted? If so, have they been corrected? When was the last inspection by the DEA (if applicable)? Were any deficiencies noted? If so, have they been corrected? Has the company ever had any disciplinary actions by a local, state, or federal authority with regards to pharmaceutical storage, handling, and distribution? YES NO If yes, please explain: Facility What is the size of the facility (in sq. feet): Is the facility VAWD Certified? YES NO APPLIED If yes, please include a copy of VAWD License. Does the company have temperature and humidity monitoring equipment? YES Does the company record temperature and humidity readings? YES NO NO Does the company have adequate refrigeration equipment with temperature humidity monitoring in place for refrigerated pharmaceuticals? YES NO Does the company have a list of excluded vendors? YES NO Does the company have an Authorized Distributor list (AD list)? YES NO The undersigned certifies that all the information provided herein is true and correct. Further the company agrees to promptly notify HyGen Pharmaceuticals, Inc. if any of the information provided should change. The undersigned must be an officer/owner of the company. Date: Name: Title: Signature: Vendor Electronic Payment Form Email: accounting@hygenpharma.com Telephone: 425-451-9178 Fax: 425-451-8964 Distributing low-priced generics Nationwide 8635 154th Ave NE, Redmond WA 98052 New Add Request Change Existing ePay Account For your convenience and benefit, all Vendors will receive payments electronically, via ACH. Your payments will be deposited into the checking or savings account of your choice. In addition to having the funds deposited electronically, you also will be notified of the deposit via e-mail. The e-mail will provide you with all the information that would normally be on your check stub. To receive payments electronically, you must complete this form, attach a voided check, and return via e-mail, or fax. PRINT the following information. Payee Name: Federal ID #/SSN #: Required E-mail Address: Vendor – Customer # Payment Terms _____________________ ____________________________ Payee Address Bank Name: Print Name and Title: Bank Routing Number: Contact Phone Number: Checking Acct #: Savings Acct #: ATTACH VOIDED CHECK OR PROVIDE A BANK LETTER WITH ACH ROUTING/ACCOUNT INFO I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, I affirm that, regarding electronic payments HyGen Pharmaceuticals Inc may remit to the financial institution for credit to the account that I have designated. The entire payment amount is not subject to being transferred to a foreign bank account. I authorize HyGen Pharmaceuticals Inc, to initiate direct deposit entries as per payment terms, to the financial institution and account identified on the attached certification document. I understand and accept the conditions of participation in the direct deposit program. This authority will remain in effect until I cancel it in writing. SIGNATURE: DATE: