A
REQUEST TO MODIFY AN EXISTING DIRECT-PURCHASE ACCOUNT
INSTRUCTIONS FOR COMPLETION:
Please complete all sections of this form. If a particular question is not applicable, please indicate with N/A. Failure to complete this form in its
entirety will result in a delay in processing.
Mail or fax the following items to the address listed below:
1. Completed and signed Request to Modify an Existing Direct-Purchase Account
2. Copies of all current state licenses, and tax-exempt certificates (if applicable)
Mail or Fax to:
Merck & Co., Inc.
Sumneytown Pike
PO Box 4, Mailstop WP39-412
West Point, PA 19486-0004
Fax # 215-631-5996
Attn: Customer Account Team
1-800-MERCK RX
Field Sales Personnel Only:
Name: ____________________
RDT: ____________________
MVX: ____________________
Cell:
____________________
Please keep a copy of this request for your records.
SECTION I.
EFFECTIVE DATE OF CHANGE: _________________________
ACCOUNT # _________________________________________
□ CHANGE TO AN EXISTING ADDRESS.
__ Address Type (please check which type applies)
□ Billing
□ Permanent Shipping
__ Reason for change:
ACCOUNT NAME ____________________________________
CONTACT NAME ____________________________________
CONTACT PHONE # _________________________________
□ ADD PERMANENT SHIPPING LOCATION
_________________________________________________
□ DELETE PERMANENT SHIPPING LOCATION
__ Relationship of New Shipping Location to Existing
Direct-Purchase Account:
__ Reason for deleting the permanent shipping location from
the Existing Direct-Purchase Account:
_________________________________________________
______________________________________________________
SECTION II.
Name of Ownership:
Street Address:
Suite #:
City/State/ZIP:
Area Code and Phone Number:
Area Code and FAX Number:
Web Site:
How Long in Business:
SECTION III. CHANGE A BILLING LOCATION
Name:
Street Address:
Suite #:
City/State/ZIP:
Company Website:
Area Code and Phone Number:
Area Code and FAX Number:
Contact Name:
Email Address:
11/19/2008
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A
SECTION IV -- ADD or CHANGE A SHIPPING LOCATION
Shipping Location Name:
Street Address:
Suite #:
City/State/ZIP:
Area Code and Phone Number:
Area Code and FAX Number:
Contact Name/Phone Number:
Email Address:
Please circle which item should
be included with the shipment:
Packing Slip
Are you a Vaccine for Children provider
F YES
Delivery Restrictions:
Invoice
If a Vaccines for Children provider, please contact your state project to change
your shipping address on your Vaccines for Children account. We are only
able to change the address on your Merck Direct Purchase Account.
F NO
PLEASE PROVIDE STATE LICENSE AND DEA LICENSE INFORMATION FOR A PHYSICIAN AT EACH LOCATION. A COPY OF THE CURRENT
STATE LICENSE AND DEA LICENSE MUST ACCOMPANY THIS APPLICATION. (For physicians, only MD or DO state medical licenses will be accepted.)
A COPY OF ALL CURRENT STATE MEDICAL LICENSES FOR ALL PARTNERS/OWNERS SHOULD ACCOMPANY THIS APPLICATION. IF LICENSED
IN MORE THAN ONE STATE, PLEASE PROVIDE A COPY OF THE LICENSE FOR EACH STATE
State(s) License #(s):
License Type:
Expiration Date:
*DEA License #: (optional)
*Name on DEA:
Expiration Date:
HIN (Health Industry Number): (optional)
Medical Education #: (optional)
Do you participate in any purchasing
contracts for Merck products?
If you answered Yes, please list the contract number(s) and name:
□ YES
□ NO
* By providing and submitting DEA License number on this Account Modification Form, Customer authorizes Merck & Co., Inc. to release the DEA
registration number provided above as necessary to process transactions.
SECTION V – DELETE A PERMANENT SHIPPING LOCATION
Shipping Location Name:
Street Address:
Suite #:
City/State/ZIP:
Area Code and Phone Number:
Area Code and FAX Number:
Contact Name/Phone Number:
Email Address:
SECTION VI
I affirm that all the information provided and the statements made on this request are true and accurate to the best of my knowledge. I agree to abide by all
State and Federal laws regarding pharmaceutical and vaccine products. I understand that falsification of information provided may result in the rejection of
this request or termination of a direct purchase account with Merck & Co., Inc.
________________________________________________________
Signature of Officer or Owner
________________________________________________________
Print Name/Title
________________________________________________________
Date
11/19/2008
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