Supplier Questionnaire Supplier Name (Legal Name) * Supplier Name (DBA Name, If Different) Owner Name * Owner Phone Number * Main Contact Name (If Different) Main Contact Phone (If Different) Main Contact Email * Main Contact Title * Billing/Finance Contact Name * Billing/Finance Contact Phone * Billing/Finance Contact EMail * Billing/Finance Contact Email (Alternate Email) Street Address * City * State * Zip * Fax Number Website * Years In Business (2+ Required) * Total Annual Sales ($) * Number of Division(s) / Locations * Size of Warehouse Facility (Square Feet) * Do you offer Controlled Substance Medications? * Yes No Do you offer Generics? * Yes No Do you offer Brands? * Yes No Do you offer OTC’s? * Yes No Do you offer DME’s? * Yes No Business Mix Pharma % * 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Business Mix Home Health % * 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Business Mix Other % * 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Business Mix Other Explanation (If Other) How many product SKU’s are in your catalog? * Number of States Licensed to Distribute in? * ADD-Accredited? * Yes No Pending DEA Licensed? * Yes No Pending What credit terms do you offer new customers? (Separate by Comma) * Payment Methods Accepted? (Separate by Comma) * Can you accept Trxade’s Universal Credit Application? * Yes No Need To Review What is your order minimum for Next Day shipping? * Daily Cut-off Time (EST Time) * 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm What Software System do you use to process orders? * Do you have EDI Capability * Yes No Pending Are you DSCA Compliant and able to provide buyers with Pedigree on all purchases? * Yes No Pending Not Needed For Our Products DSCA Compliant - If yes, what system are you using to generate pedigrees and how will they be issued to buyers?
Manufacturer Affiliations (If Any) Buying Group Affiliations (If Any) Do you hold the same address as a pharmacy? * No Yes Do you buy Rx from Pharmacies to resell? * No Yes Do you do business with government entities? * No Yes When was your last Inspection by the State? * 0-6 Months 6-12 Months 12-24 Months
Important: Please email photographs of your Warehouse, 3 pedigree/T3 examples, and a copy of your last inspection by the board of pharmacy to Operations@Trxade.com to help expedite your application.
Photographs Needed: Outside of Building, Customer Service Area, Warehouse Facility, & Shipping Area