Burlington Drug Company   FAX 802-893-5104                              



Legal Name of Store: ________________________________________ FED ID #_____________

Trade Name of Store: _____________________________________________________________

Store Street Address: ______________________________________________________________

City, State, and Zip Code: __________________________________________________________

Billing Address: ____________________________________E-Mail Address: ________________

Telephone #: (____)___________Fax # (____)____________Type of Business: _______________

Type of Ownership: Corporation _______ LLC ______ Partnership _____ Sole Proprietor _______ 


Name ________________________ Title: _____________  % of Ownership ______ SS #__________

Name ________________________ Title: _____________  % of Ownership ______ SS # __________

Owner’s Home Address:___________________________________________________________________

Do You Own or Rent Your Store Real Estate? Own: ____ Rent: ____

How long has present owner operated this business? ______________

Ever-Declared Bankruptcy? Yes ___ No___               Credit Requested $ ____________

Bank Information

Name of Bank: __________________________________      Contact: _____________________

Bank Address: __________________________________      Phone: (____) ________________

Account Type: __________________________________      Account #: ___________________

List Three Major Trade Suppliers / Credit References (Must include current primary supplier)

Name                                                                         Account #           Phone #                Avg. Purchases

1. ____________________________________                  _____________      _____________         $_____________

2. ____________________________________                  _____________      _____________         $_____________

3. ____________________________________                  _____________      _____________         $_____________


Required Attachments:

 ___Copy of Rx Label, ____Copy of DEA Registration____ Copy of the Two Most Recent Primary Supplier Statements

 ____Copy of Sales Tax Exemption (Resale), Sales Tax # _______________

Established Business: A copy of your latest financial statement is beneficial in establishing a line of credit. 

New Business: Please supply information regarding experience in this new line of business, personal credit references, and any other general information, which may help to establish the credit record of this new business.


Customer Agreement: I (we) agree to pay all invoices when due per terms on the invoice.  I (we) further agree to pay the 1.5% per month (18% per annum) finance charge on past due invoices as stated in current policies on our invoices.  If it becomes necessary to take legal action to collect this account, all legal fees, including attorney’s fees, shall be added to the total indebtedness on this or any other account I (we) owe to Burlington Drug Co., Inc. and agree to personally guarantee payment of all amounts due.  I (we) give Burlington Drug Co., Inc. permission to check our personal and business credit and contact our credit references proded..

Customer Signature: ________________________________                        Date: ____/____/____

Customer Name Printed: _____________________________

Co-Owner’s Signature: ______________________________                        Date: ____/____/____

Co-Owner’s Name Printed: ___________________________




THIS GUARANTY, dated as of _______________, ____, 200___, by _____________________________ (the "Guarantors"), in favor of Burlington Drug Co., Inc., a Vermont cor­poration with­ place of business at 91 Catamount Drive, Milton, Vermont, 05468 (the "Lender") is made in consideration of the Lender's opening of a business account for ___________________________ (“Customer”), which account may be used to purchase products and services from the Lender.  Customer acknowledges and agrees that this Guarantee is an inducement to Burlington Drug Co., Inc. to extend credit to the Customer, and without this Guarantee, Burlington Drug Co., Inc. would not extend such credit.  In consideration of the foregoing, the Guarantors agrees as follows:

The Guarantors hereby guarantee to the Lender, jointly and severally, the full and punctual payment when due, and the performance of all liabilities, agreements and other obligations of the Customer to the Lender, whether absolute or contingent, due or to become due, secured or unsecured, and it shall extend to all indebtedness incurred by the Customer to Lender on or after the date of this Guarantee (the "Obligations").  This Guaranty is an absolute, unconditional and continuing guaranty of the full and punctual payment and performance of the Obligations.  It shall apply to all future indebtedness of the Customer to Lender.  This Guaranty is in no way conditioned upon any requirement that the Lender first attempt to collect any of the Obligations from the Customer or resort to any security or other means of obtaining their payment.  Should the Customer default in the payment or performance of any of the Obligations, the obligations of the Guarantors hereunder shall be­come immediately due and payable to the Lender, without demand or notice of any nature, all of which are expressly waived by the Guarantors.  Payments by the Guarantors hereunder may be required by the Lender on any number of occasions.

The Guarantors further agree, to pay to the Lender, on demand, all costs and expenses (including court costs and legal expenses) incurred or expended by the Lender in connection with the Obligations, this Guaranty and the enforce­ment thereof, together with interest on amounts recoverable under this Guaranty from the time such amounts become due until pay­ment, at the maximum interest rate permitted to be paid under applicable law. 

The guarantee may be revoked by written notice to Lender from the undersigned.  The revocation shall take effect only after receipt of written notice by Lender.  Notice of acceptance of this guarantee is waived.  The liability of Guarantor shall not be affected by extension of time of payment by the Lender, by the existence of or changes in collateral securing the debt, or by release of the Customer from the Obligations or the release of any other guarantors.

The Guarantors waive any notice of default or non-payment.  No amendment or waiver of any provision of this Guaranty, nor consent to any departure by the Guarantors therefrom, shall be effective unless it is in writing and signed by the Lender. No failure or delay by the Lender to exercise any right hereunder shall operate as a waiver thereof; nor shall any par­tial exercise of Lender’s rights preclude any other exercise thereof or the exercise of any other right.  The laws of Vermont shall govern this Guaranty and any enforcement hereof shall be brought in either state or federal court in Vermont.  The rights and remedies provided herein are cumulative and not exclusive of any remedies provided by law or any other agreement, and this Guaranty shall be in addition to any other guaranty of the Obligations. The invalidity or unenforceability of any one or more sections of this Guaranty shall not affect the validity or enforceability of its remaining provisions.



Legal Name of Store / Customer


___________________________________________                         ___________________________________________

Guarantor's Signature                                                                                         Guarantor's Home Address

____________________________________________                         __________________________________________

Guarantor's Printed Name                                                                                    Date

____________________________________________                         __________________________________________

Guarantor's Signature                                                                                          Guarantor's Home Address

____________________________________________                         __________________________________________

Guarantor's Printed Name                                                                                   Date