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: