DISPENSARY

Registration

Last Name*

Middle Initial

First Name*

Email Address*

Contact Number*

DISPENSARY INFORMATION

Dispensary Name*

Registered Business Name

Business EIN*

Street Address*

Apartment, Suite, Building, Floor, etc.

Country*

State*

City*

ZIP / Postal Code*

Upload Due Diligence / Requirements (pdf, jpeg, png ; max of 10mb)

State License*

License Number*

Valid Until*

Upload Registry License

Choose files

Product List

(download product list template)

Choose file

Bank Details *

Choose file

W9 Form *

Choose file