New Customer Form

We are always happy to see new customers! Please fill out the form below and we will be in touch within 24 hours with next steps for your account setup.

Business Information
Trade Name
Preferred DBA
Tier*
SELECT CUSTOMER TYPE
- Tier 1
- Tier 2
- Tier 3
- Medical
- Retailer
- Personal
- Analytics Lab
- Processor
- CBD (no THC)
Store Name*
UBI #*
License #*
License #2
License #3
Healthcare Practitioner Name*
Healthcare Practitioner License #*
If you do not have an LCB License or a Medical Authorization you will need to provide a receipt as proof of purchase.
Business Phone
Grow Type
SELECT GROW TYPE(S)
- Indoor
- Outdoor
- Greenhouse
- Variable
- Processor Only
- N/A
Addresses
Physical Address
Physical Address Address Line 2 City State ZIP Code
Mailing same as Physical?
- Check this box if your MAILING address is the same as your PHYSICAL address
Mailing Address
Mailing Address Address Line 2 City State ZIP Code
Billing same as Physical?
- Check this box if your BILLING address is the same as your PHYSICAL address
Billing Address
Billing Address Address Line 2 City State ZIP Code
Sample Results Contact(s)
Name
First Last
Phone
Email
Add 2nd Contact
- Check this box to add another RESULTS contact
Name
First Last
Phone
Email
Add Contact
- Check this box to add another RESULTS contact
Name
First Last
Phone
Email
Transportation Contact(s)
Name
First Last
Phone
Email
Add Contact
- Check this box to add another TRANSPORT contact
Name
First Last
Phone
Email
Add Contact
- Check this box to add another TRANSPORT contact
Name
First Last
Phone
Email
Billing Contact(s)
Name
First Last
Phone
Email
Add Contact
- Check this box to add another BILLING contact
Name
First Last
Phone
Email
Add Contact
- Check this box to add another BILLING contact
Name
First Last
Phone
Email
Referral Source*
SELECT REFERRAL SOURCE(S)
- Website
- MJ Venture
- Dope Magazine
- Leafly
- Word of Mouth
- Event
- LCB
- Other
Who referred you?*
Other*
New Customer CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Payment Terms

By using our services, you agree to pay upon completion of results unless other terms have been made. We observe standard business practices for services rendered.