Dispensary Registration – Green Spectrums

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Email *

Password

Dispensary Information

Dispensary

OCM License #: *

Delivery Address: *

Tax ID/EIN# (include W-9): *

Legal Business Name: *

Billing Address (if different): *

Resale Certificate (NY form ST-120): *

Accounts Payable Contact

Accounts Payable

First Name: *

Email: *

Last Name: *

Phone: *

Buyer Contact

Buyer

First Name: *

Email: *

Last Name: *

Phone: *

Intake/Delivery Coordinator

First Name: *

Email: *

Intake Days & Times: *

Last Name: *

Phone: *

Delivery Instructions: *

Green Spectrums is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

I agree to receive other communications from Green Spectrums.

You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy. By clicking submit below, you consent to allow Green Spectrums to store and process the personal information submitted above to provide you the content requested.

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