Registration

*Last Name

Middle Initial

*First Name

*Email Address

*Contact Number

DISPENSARY INFORMATION

*Dispensary Name

*License Number

*Street Address

Apartment, Suite, Building, Floor, etc.

*Country

*State

*City

*ZIP / Postal Code

*Dispensary Domain Name (at least 3 names)

*Is the owner a pharmacist? Yes No

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

State Board License / DEA License

Choose files

Product List

Choose file

Bank Details

Choose file

W9 Form

Choose file