Success
Error
    Please select your business from the list below
     

    Don't see your business here? Try one of the options in the drop down box or proceed by choosing 'Business Not Listed'.

    General Information

    *
    $
        

    *
     Yes    No
        

     
        

     
        
    *
        

    Company Information

    *
        
     
        

    *
        
    *
        
    *
        
    *
        
     
        
    *
        
    *
        
    *
        
    *
        
     
        
    *
        
    *
        
    *
        

    *
        
    *
        
    *
        
    *
        
    *
        
    *
        
     
        
    *
        
     
        

    If yes attach tax exemption certificate below

        
        
    *
        

    If yes attach copy of medical license below

        
        
    *
        
    *
        

    Attachments

    If applicable, please attach copy of Tax Exempt certificate and/or Medical license. Please provide in PDF format.
    Attachment Description Attachment Location
    Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.

    Terms and Conditions

     
    *
        
    *
        
    *
        
    PRINT AGREEMENT
    * I agree to the terms and conditions specified above.

    User Verification

    Please complete the following by entering the value EXACTLY how it appears(case sensitive)
     
     



    Why do I have to do this?