Become a Retailer

Here is main company information for your profile. Please complete or update the following information.

 

General Information

Company/Clinic Name *

Business Licenses No. *

Business Type

Account Type

Account Contact First Name *

Account Contact Last Name *

Title

Email *

Address *

City *

Province

Postal Code (eg: A1A 1A1) *

Phone Number (eg: 123-456-7890) *

Fax Number (eg: 123-456-7890)

Website (eg: http://www.anysite.com)

Is this an Ecommerce Website?

GST/HST Number *

 

Please attach the following:

Business License *

Please attach only .png, .jpg, .jpeg, .pdf formats. Files must be less then 5 MB.



 

Business Hours

Please indicate what hours you are open.

Sunday:

Open

Close

Monday:

Open

Close

Tuesday:

Open

Close

Wednesday:

Open

Close

Thursday:

Open

Close

Friday:

Open

Close

Saturday:

Open

Close



Billing Information



Accounts Payable Contact Name *





Email *

Address *

City *

Province *

Postal Code *

Phone Number *

Fax Number



Shipping Information



Shipping Contact Name *





Email *

Address *

City *

Province *

Postal Code *

Phone Number *

Fax Number



Set Password

Password (min 8 digits, must contain Uppercase, Lowercase and Number) *

Confirm Password *

 

Terms & Conditions



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