medical center registration form

medical-center

Register

Legal business name *
Dispensary name* *Your dispensary is where your patients will purchase supplements. You can use your practice name here. If you don't want to customize it, we'll use your first and last name
Business owner name *
Business identification number
Email *
Main phone number *
Address (number, street, and apt. or suite no.)
City, state, and ZIP code

Country

I accept the I agree to The Functional Market´s Terms of Service and Privacy Statement . *

Required documents (PDF only) * Chamber of Commerce Certificate - COL / Employer Identification Number -

Resale Certificate for Sales Taxes (RUT - COL / Annual Resale Certificate - USA) * Resale Certificate for Sales Taxes (RUT - COL / Annual Resale Certificate - USA)

Password *
Confirm Password *

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medical center registration form

medical-center

Register