Registration Step 1:

Fill out the following form

Please fill out all fields. Once complete you must print, fill out, and return the KY Meds Check Draft Authorization Form.

If you would prefer to download the application and fax/email, please click here to download.

Company Information

Company Name:

Billing Address:

Shipping Address:

Contact Info:

License Info

**Copy of license must be faxed or emailed**

Business Type

RetailLTCSpecialty CenterOther**

PRINCIPAL OFFICERS AND/OR PARTNERS

1.
2.

Purchasing Agent

CREDIT REFERENCES



**You will be contacted directly for account details

We authorize you to check our company credit rating and verify the information provided in this credit application. By
signing, using, or requesting issuance of credit by KY Meds Inc, we agree to the following:
1. This is an unconditional personal guarantee for all credit extended by KY Meds Inc or its subsidiaries in connection with the purchase of any and all goods. Further, the guarantor agrees to subject their company to the jurisdiction and venue of the Kentucky courts.
2. We understand our terms are Net 20 subject to credit approval and agree to pay at the place designated on the invoice all drafts and obligations, evidence of credit, and all extensions of credit, and all finance charges when imposed, either
a. In full upon due date, or
b. If not paid upon due date, a 1.5% monthly finance charge will be assessed
c. On default or failure to pay as agreed, you will pay to KY Meds Inc or its subsidiaries collection costs, the maximum monthly finance
charge permitted, and reasonable attorney’s fees.
d. Customer agrees to pay a 20% restocking fee on all AUTHORIZED returns. No Credit will be given to UNAUTHORIZED returns.
3. We hereby grant permission to KY Meds Inc. and its subsidiaries to send advertising and promotional materials to the email(s) and fax
number(s) listed above. This operates as consent under the 47 U.S.C. § 227 of the Telephone Consumer Protection Act.
4. This agreement is binding on your representatives, successors, and assigns.

Name:

Signature:

Registration Step 2:

Download, print, fill out, and return the KY Meds ACH Form via email to accounting@kymeds.com or fax to 877-683-2065

Fill out the ACH form and return it via email or fax: