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New Account Page

Instructions for setting up a new account:

To order Endura-KT, please first set up your new account by downloading and completing the application that corresponds with your group (physicians or hospital pharmacies). By completing the application, you will stay in compliance with State and Federal requirements.

Once you’ve completed the application, please send it to our corporate office for review and approval.

It is critical that you fax your application to (800-537-0857) or scan and email your application to (admin@ventispharma.com) with a copy of your facility’s state license or physician state license.

If you prefer, you may also provide all this information to your Ventis Pharma sales agent.

If you have any questions, please call Ventis Pharma at 800-441-5841. We are happy to help you through this process.

Thank you for your interest in Endura-KT

Ventis Nubratori Provider Account

Ventis Nubratori Pharmacy Account

NUBRATORI RX

New Account Checklist

When submitting a new account please submit the following items by fax to (310) 347-4338 or email to info@nubratorirx.com

Account Name:

Reference ID:

(please include this page when returning account paperwork)

Provider Profile Questionnaire

Please Verify all questions are compeleted

Provider Terms and Conditions of Sale

Provider State License(s)

Credit Card Form

Designation of Agent

NUBRATORI RX

Provider Profile Questionnaire

Provider Name:

Facility Name:

Address:

City,State,Zip:

Phone:

Fax:

Email:

State and License Number:

Expiration Date:

Type of Practice:

Are you licensed in any other states?

Yes No

If yes, please list each state you currently hold a license in:(Please provide a copy of each license ):

Please Provide the facility name(s) and address(es) for all locations you practice at and will be purchasing and dispensing Pharmaceutical itemsL:

Physician's Facility Information:
(Please complete all questions as questionnaies with blank answers will not be processed)

How many patients do you see in a day?:

How many patients do you see each month?:

How are medications stored in your office?:

If you answered “yes” to any of the questions above, please give a brief description:

Providers Name:

Providers Signature:

Title

Date

Physicians Designation of Authorized Agent(s)

I do not authorize anyone to act on my behalf at this time. I will place my own orders.
I authorize my agent(s) to place orders on my behalf.

Designated Agent(s)

Name:

Title:

Signature:

Date:

Email address:

Name:

Title:

Signature:

Date::

Email address:

Name:

Title:

Signature:

Date::

Email address:

Name:

Title:

Signature:

Date::

Email address:

Name:

Title:

Signature:

Date::

Email address:

I certify that all the information I have provided is true, complete and correct

Providers Name:

Providers Signature:

Title

Date

I do not authorize anyone to act on my behalf at this time. I will receive and make payment on my own invoices.
I authorize my agent(s) to receive and make payment on invoices on my behalf.

Designated Agent(s)

Name:

Title:

Signature:

Date:

Email address:

Name:

Title:

Signature:

Date::

Email address:

Name:

Title:

Signature:

Date::

Email address:

Name:

Title:

Signature:

Date::

Email address:

Name:

Title:

Signature:

Date::

Email address:

Original invoices will be sent to the provider, a copy of all invoices can be sent to the following address for accounting and payment if provided below:

I prefer electronic invoices.

Email address:

I prefer paper invoices.

Address:

I certify that all the information I have provided is true, complete and correct

Providers Name:

Providers Signature:

Title:

Date:

NUBRATORI RX

MEDICAL PROVIDER TERMS AND CONDITIONS OF SALES

Following are the Terms and Conditions of all sales and transactions between Nubratori Rx and medical providers, all hereinafter collectively referred to as “Provider.” By signing below, Provider acknowledges and agrees that all transactionbetween Provider and Nubratori Rx are subject thereto:

1. Provider acknowledges that all Nubratori Rx products are for office use only and not be to re-sold. Provider can only dispense or administer Nubratori Rx products to its own patients.:

(initial)

2. Provider acknowledges that all orders placed for Nubratori RX products are for patients that the provider believes will have a significant clinical difference over other commercial products on the market

3. Provider agrees NOT to alter or tamper with the labeling or packaging of any Nubratori Rx product.

4. Provider understands and agrees that pricing for Nubratori Rx products are subject to change without prior notice.

5. Provider understands and agrees that some Nubratori Rx products are only sold in case sizes/quantities.

6. Provider agrees to report any order discrepancies within two (2) business days.

7. Provider agrees that any unused, expired, or unwanted Nubratori Rx products are to be disposed of according to all local, state and federal laws or regulations applicable to their licensure and the jurisdiction in which they conduct business.

8. Provider acknowledges that Nubratori Rx Products cannot be returned.

9. Provider must strictly abide by and observe all shipping, storage, return and non-circumvention policies of Nubratori Rx, and Provider further agrees to store and handle all products in proper and appropriate conditions and temperatures as per manufacturer labeling, industry custom, and applicable laws and regulations concerning such.

10. Provider agrees to observe and abide by all local, state and federal laws, rules and regulations applicable their licensure and jurisdictions in which they conduct business

11. Provider agrees to indemnify and hold Nubratori Rx harmless for all losses or damages suffered as a result of violations of these Terms and Conditions, or as a result of violation of any local, state or federal law or regulations concerning the possession, administering or dispensing of Nubratori Rx products

12. Provider represents and confirms that it is fully insured for any liability or loss that may arise in connection with the purchase, possession, administering or dispensing of Nubratori Rx products

13. Provider agrees NOT to display any Nubratori Rx product on their website or other electronic medium without Nubratori Rx’s prior written consent

14. Provider agrees NOT to use or disseminate any marketing material concerning or advertisement relating to Nubratori Rx products without the prior, written consent of Nubratori Rx prior to such use

15. Provider understands and acknowledges that in certain circumstances certain Nubratori Rx products may not be available due to manufacturing backorder issues beyond the control or scope of Nubratori Rx.

16. Provider shall NOT attempt to, or actually, copy, imitate, or create any products similar, same as, or competitive against those offered by Nubratori Rx

17. Provider is fully aware and acknowledges that all Nubratori Rx products are protected by patents and/or pending patents, and all labeling and marketing material is protected by copyright and/or trademark, and, further, Provider specifically agrees NOT to violate such patents, trademarks or copyrights, nor to engage in any activity inconsistent therewith by attempting to, or actually, copying or imitating any Nubratori Rx product, labeling, or marketing material

18. All orders must be pre-paid by Provider prior to shipping from Nubratori Rx’s facility. For orders under $5,000, a credit card is acceptable means of payment. For orders over $5,000, 50% non-refundable deposit shall be wired at time of order and the balance must be wired by Provider to Nubratori Rx prior to shipping

19. Accounts qualify to submit an application for credit after being established with Nubratori Rx for at least six months. Credit will be granted or denied pursuant to the unfettered discretion of Nubratori Rx, and subject to these Terms and Conditions, and any breach or violation of these Terms and Conditions by Provider shall also constitute a breach and violation of credit extended to Provider. Nubratori Rx requires one or more personal guarantees for the extension of credit to Provider and to guarantee Provider’s strict adherence to these Terms and Conditions.

20. Nubratori Rx reserves the right to accept or reject any order. Furthermore, Nubratori Rx reserves the right to cancel any order or account at any time, without recourse, and pursuant to its unfettered discretion

21. Nubratori Rx retains the right to change, modify or alter its Terms and Conditions of Sales at any time

22. Any and all dispute arising from, or relating to, any sale or transaction between Provider and Nubratori Rx, or arising from or relating to these Terms and Conditions of Sales, shall be governed by California law and be brought exclusively in the Superior Court of California, County of Los Angeles. The prevailing party in such dispute, action or proceeding shall be entitled to their attorneys’ fees and costs, in addition to any other relief allowed by law or so granted by the court.

IT IS SO AGREED:

Nubratori Rx:

Date:

(Signature):

Date:

By: Robert Nickell

By:

(Print name)

Its: CEO

Its:

(Corporate/organizational capacity or title of signer

NUBRATORI RX

381 Van Ness Ave Suite 1507, 1508 Torrance, CA 90501

Ventis Pharma P. 310.218.4153 F. 310.347.4338

Account Name:

A.P Contact:

Phone Number:

Email Address:

Select Payment Type

Visa

MasterCard

American Express

Credit Card Account Number:

Expiration Date:

Security Code:

Ihereby request and authorize Nubratori RX to apply payments of all invoices to the credit card listed above. Card member agreesto perform to obligationsset forth in the Card member’s agreement with the issuer. All sales are final. Errors must be reported to Nubratori RX within 72 hours of receipt for exchange. Payments are applied on date ofshipment.

Cardholders Signature:

Date:

BILLING INFORMATION FOR CREDIT CARD

Company Name

Street Address & Suite # (Address for billing)

City, State, Zip Code

Telephone

Fax Number

New Account Page

Ventis Nubratori Provider Account

Ventis Nubratori Pharmacy Account

NUBRATORI RX

New Account Checklist

NUBRATORI RX

Physician's Facility Information: (Please complete all questions as questionnaies with blank answers will not be processed)

Physicians Designation of Authorized Agent(s)

Designated Agent(s)

Designated Agent(s)

NUBRATORI RX

NUBRATORI RX

BILLING INFORMATION FOR CREDIT CARD

Physician's Facility Information:
(Please complete all questions as questionnaies with blank answers will not be processed)