EBudgetTM Enrollment Form



|[pic] |eBudget® Service Enrollment Form |

|Thank you for choosing PharmaLink’s eBudget® Returns System. Please select the plan you would like to enroll in, and fax this sheet to (727) 669-8327. Upon receipt of |

|your fax, a representative will contact you to validate your request. |

|Pharmacy Information |

|Company Name: |Phone: |

|Contact: |Fax: |

|Address: |PID#: |

| |Sales Person: |

|Program Selection (Select the program that you would like to enroll in) |

| | |

|eBudget® Bi-Monthly Returns Program |eBudget® Quarterly Returns Program |

|Includes: |Includes: |

|(1) One return every other month (6 returns annually) |(1) One return every quarter (4 returns annually) |

|Return Supplies ((1) tote, eBudget web access, prepaid shipping labels) |Return Supplies ((1) tote, eBudget web access, prepaid shipping labels) |

|Complete returns processing and disposal |Complete returns processing and disposal |

|Complete customer service and technical support |Complete customer service and technical support |

| | |

|Fee: $249 Bi-Monthly |Fee: $249 Quarterly |

| |

|Authorization |By signing, I agree to the eBudget® Terms and Conditions listed at the bottom of this page. My signature is authorization for PharmaLink to make |

| |payments on my account from my credit card and/or checking account. |

| |

|Authorized Signature:. Printed Name: Date:. |

|. |

eBudget® Terms and Conditions

Thank you for enrolling in the eBudget® Program, the next generation in pharmaceutical return services. We are confident that you will enjoy the benefits of the program such as: its convenience and ease of use, all at a low fixed fee. PharmaLink, Inc.® provides you with (1) tote, web access to specially designed inventory software, a barcode scanner, and the necessary supplies to prepare returns.

Terms of Offer

PharmaLink is so confident of the advantages of the eBudget Program that you will never want to use any other method to handle your returns. Upon signing, you will automatically be enrolled and the first processing fee of the plan you selected will be debited from the payment method you specified at the time of your enrollment. A one time contract set-up fee of $99 will also be bill to your account.

Our eBudget Program allows you to return one tote every billing period. We understand that, at times, some pharmacies require more than one tote. When this is the case, we will charge an additional tote fee according to your plan. If necessary, additional totes can be sent to you by simply calling (800) 257-3527. For your convenience, additional totes will automatically be billed to the payment method previously specified.

C2 Service

C2 services are NOT included in the eBudget Program. Additional fees will be charged to your credit card or other payment information provided at a rate of $25.00 per DEA form 222, plus a 12% ERV processing fee; and a $10.00 flat fee for disposal. A minimum processing fee of $99.00 will apply for C2 returns. You may submit a C2 request form online at .

Payment Policy

Your eBudget Program fee will be billed automatically either bi-monthly or quarterly, according to the plan you selected at the time of enrollment. All payments are processed on the 1st of each billing period following the enrollment date. For your convenience, we will automatically renew your program after 12 months from the original date of your enrollment. Every effort will be made to maintain contracted prices, however PharmaLink reserves the right to adjust pricing as it deems necessary in order to maintain the highest quality of service.

Cancellation Policy

PharmaLink understands that circumstances could avail themselves where you may have to cancel the service. If this is the case, simply contact our customer service department for cancellation guidelines. You will still be responsible for the fees owed during the term of the agreement as well as for any outstanding fees on your account.

Our Customer Service department is always ready to assist you with any questions or concerns. Please call us directly at (800) 257-3527, and one of our customer service representatives will be happy to assist you.

PharmaLink, Inc. is not responsible for any overdraft/over-the-limit charges or bank fees if your account contains insufficient funds when your order is processed and billed. All service fees are non-refundable. If it is determined that a refund is due, PharmaLink will issue a pro-rated in-house credit for any outstanding products and/or services for the contractual period.

We recommend using a credit card rather than a debit card. Note to Debit Card users: canceling too close to the renewal date may cause a processing delay and a charge to your account. If you are eligible for a refund, refunds can take up to 30 days to be processed.

This service agreement will be governed by the laws of the State of Florida.

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