To set up an account with Sterling Distributors, please simply fill out the form, below.
After submitting your New Client Form, a Sterling Distributors Sales Manager will contact you to help you place your first order.  * = Required Fields.
New Client Form

*Contact Name:
*Legal Company Name:
*Trade Name:
*Address:
 
Address 2:
*City:
*State:
*Zip/Postal Code:
Country:
*Telephone:
*Fax:
How did you hear about us?

 
 
*Trade Class: Pharmacy, Home Health, Hospital, Etc.
DEA #
Pharmacist Name
State Pharmacy Permit #
 
Officers/Partners
1 *Name:
1 Title:
1 *Home Address:
1 Social Security:
1 DOB:
   
2 Name:
2 Title:
2 Home Address:
2 Social Security:
2 DOB:
 
Bank References
*Name of Bank:
*Phone #

*Account #

 
 
Credit References
1 Company:
1 Contact:
1 Address:
1 City/State/Zip:
1 Phone:
1 Fax:
1 Account #
   
2 Company
2 Contact:
2 Address:
2 City/State/Zip:
2 Phone:
2 Fax:
2 Account#:
3 Company
3 Contact:
3 Address:
3 City/State/Zip:
3 Phone:
3 Fax:
3 Account#:
 
Bankruptcy Disclosure
    Has the customer or any kind of its officers, partners or shareholders previously filed for protection in a bankruptcy court:
 

*Choose Yes or No :

   Date of Filing: Date of Discharge:
Address of Bankruptcy:
City/State/Zip:
 
Consent to Disclosure
 

The undersigned hereby gives permission to references given to disclose to Sterling Distributors any information, which they have in their files regarding companies and persons listed on this application, and to respond to any inquires made by Sterling Distributors concerning these persons financial condition.

Permission is granted through this signature allowing Sterling Distributors to check the consumer credit of all parties listed on this Credit Application document

 
Signed: Date: Position
 
 
Email: