Dispensary Name*

Legal Business Name (if using a DBA)

Address*

Remittance Address (if different from above)

Primary Contact*

Primary Phone*

Primary Email*

Ordering/Manifest Contact *

Ordering/Manifest Phone

Ordering/Manifest Email *

Accounts Payable Contact*

Accounts Payable Phone*

Accounts Payable Email*

OCM License Number*

File upload*

OCM License

Submit