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        If you are a previous customer of ours, we have directed you to this page just this first time.  After this first time, you will not have to come to this page.  if you will fill out the form below, we may be able to find you in an old data base.  if so, then you may not need to fill out so much information for us.  if we cannot find you, however; then we will need all of you information.

Previous Customer Form

      If you are not a previous customer, click on "Customer Accounts" above,  and then follow the link to "New Customers."

    If at all possible, use information as of about 3 years ago.  If you do not have that information, please fill this form out as completely as possible

Name        

Address       

City                      State              ZIP    

Social Security Number    

Current Telephone Number          

Current FAX Number                    

Current Email Address                  (someone@someplace.com)

Old Account Number (if Known)           

Other information you think may help us:

    Check the form to make sure it is filled out to the best of your recollection.  We will get back to you as soon as possible for any additional information that we may need.

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

        When you are sure it is correct, push the "Submit"  Button below, and sent the form.

    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.

Thanks for your help, and we will get back to you as soon as possible using the above telephone number or FAX number.

06/12/2004