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APD FOP Form

Download Payment Authorization Form

Please download and complete the payment authorization form to securely provide your billing information. Once filled out, email the signed form to info@americanapd.com to proceed with your account setup or payment processing.

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DBA Name

Company Name

GLN Number

Shipping Information

Shipping Address

Shipping Suite

Second Checkbox Number

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Billing Information

Billing Address

Billing Suite

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Contact Information

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Fax

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NPI Number

Phone

State Licenses Number

DEA Licenses Number

DEA License Upload

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PIC Pharmacist License

Agreements

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I agree to the Terms and Conditions

Last updated: 2025-06-23

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I consent to receive SMS messages. Msg & data rates may apply.

Electronic Signature Consent

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By signing below, I affirm that I have reviewed and agree to the Compliance & Terms and Conditions (version 2025-06-20), consent to use an electronic signature, and acknowledge it is legally binding under ESIGN/UETA.

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+(855) 469-2300

APD FOP Form

Download Payment Authorization Form

Download the Form

Shipping Information

Billing Information

Contact Information

Ownership Information

Agreements

Download Terms & Conditions

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