You are Here:  New Customers  |  Customer Accounts  >>  Accounting Department  >> Home  |  Site Map

        To enable you to order over the Internet, you must first come into Bullard Pharmacy, or fill out the following form here on the Internet web-site.  The items indicated with an asterisk MUST be filled in or we will be unable to process your application.

New Customer Form    

    We will need all of the information asked for below in order to process your application.  If all of the information asked for is not filled out, the application process will be slowed, or we may not be able to process your application

First Name  *    Middle Initial 

Last Name   *

Address      *

City              *   State    *  Zip   *

Social Security Number     *

Telephone Number  *

Your FAX Number (If you have one)  *

Email Address             (Someone@someplace.com)

Employer                     *

Employer Address:   

Employer Telephone  *

    We will check references and do a credit check through a national credit reporting agency.

    If / When you send  e-mail to Bullard Pharmacy, WE DO NOT give out  (or sell)  your e-mail address to anyone.  It is known only to us and remains confidential

06/07/2004