New Client Application

Rufford Pharmaceuticals, LLC
Account Application

Please contact the following with questions:

Customer service department: 901-441-6060 extension 1004
customerservice@ruffordpharma.com

Jerry Cain, VP Sales: 270-559-9513 cell phone
jerry.cain@ruffordpharma.com

Tim Booth, Chief Executive Officer: 901-570-0706 cell phone
tim.booth@ruffordpharma.com
901-441-6061 Office Line

Step 1 of 4

Invoice Information

Invoice Company Name(Required)

Invoice Account Contact Name(Required)

Invoice Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Fax #(Required)

Email(Required)

Class of Trade

State License #(Required)

Federal Tax ID #(Required)

DEA #(Required)

Is shipping information the same as invoice information?(Required)

Yes

Shipping Information

Shipping Company Name(Required)

Shipping Account Contact Name(Required)

Shipping Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Credit References

Supplier

1. Supplier Name

1. Supplier Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

1. Account Number

2. Supplier Name

2. Supplier Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

2. Account Number

3. Supplier Name

3. Supplier Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

3. Account Number