A.F. Hauser, Inc. – Pharmaceutical Distributors, Wholesalers
    Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.     Not Finding What You're Looking For?   Please Call 1-800-441-2309 for Immediate Assistance.   Note: We only ship within the USA and do not import or export.
Please fill in our New Account Form to open a new pharmaceutical account with us and/or complete our Credit Application below to expedite doing business with Hauser Pharmaceutical.  A customer service representative will get back to you shortly. Our FCC Consent Form is below also. Thank You, in advance, for trusting in our company. 
Note: Each form must be submitted individually.
 

New Account Form

* All Fields Required
General Information
 
Date :
Your Name :
How did you hear about us? :
Clinic Name :
Doctors Name :
Billing Address :
City :
State :
Zip :
Business
Residential
Same as Shipping
Yes
No
Shipping Address :
City :
State :
Zip :
Business
Residential
Phone# :
Fax# :
Email :
Permission for A.F. Hauser, Inc. to contact the above listed practice via FAX and/or EMAIL:
IS APPROVED
IS NOT APPROVED
As Per (Name):
Date:
Type of Practice :
Primary Contact :
Accounting Contact :
D.E.A# :
Exp :
Schedules :
State License# :
Exp :
Payment Options:
Visa
Mastercard
Discover
American Express
Direct Debit
Card# :
Exp :
CV2 :
Card Holder :
Card Address Street :
City :
State :
Zip :
Hours :
Security Code\A0:
   

Credit Application

* All Fields Required
Business Information
 
Date :
Legal Name of Business :
DBA :
Billing Address :
City :
State :
Zip :
Same as Billing
Shipping Address :
City :
State :
Zip :
Email :
Business Phone :
Business Fax :
Tax I.D# :
Accounts Payable Manager :
Yes No
Contact/Buyer Name :
Years In Business :
Have You Ever Filed Bankruptcy? :
Type of Ownership :
Sole Proprietor :
Partnership :
Corporation :
Owner/Officer Name :
S.S.# :
Home Address :
City :
State :
Zip :
Home Phone :
Home Fax :
Bank Reference:
Bank Name :
Account Number :
Bank Address :
City :
State :
Zip :
Bank Phone :
Bank Contact :
Trade Reference:
Name :
Account# :
Fax# :
A.F.Hauser, Inc. checks all references by fax only, please include fax numbers for ALL references
Signature :
Date :
Print Name :
Security Code :
 
   

FCC Consent Form

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