Premise License Requirements Request

Please complete this form with the following information.
The first name, last name, phone and email are for point of contact (POC).
Upon submission, you will be provided a link to download a PDF that will need to be completed and sent back with an attached copy of your Premise license.
Once the PDF is completed, email the completed PDF and a copy of your Premise license (if applicable) to the address supplied.
For any questions, please contact customer care at 800-521-5767

POINT OF CONTACT

The individual filling out this form is considered the point of contact (POC) that we will use to reach out to for any questions.

First Name(Required)

Last Name(Required)

Facility Name(Required)

Email(Required)

Phone number(Required)

State(Required)

Please Provide Your Premise License Information(Required)

Please Provide Your Premise License Information(Required)

Premise License Number(Required)

Premise License Expiration Date(Required)

Please upload a Premise License certificate.(Required)

Accepted file types: jpg, png, pdf, tiff, Max. file size: 4 GB.

Premise License Exemption Reason(Required)

Premise License Exemption Reason(Required)

Premise License Exemption Reason(Required)

Application pending(Required)

I am in the process of applying for my Premise License and acknowledge without a Premise License I cannot purchase prescription products.

Comments

This field is for validation purposes and should be left unchanged.