Practitioner application

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Practitioner application

Clinic/Business Name

Practitioner Name

Email Address

Phone Number

Shipping Address

As part of this application, we request you submit the following documents:

Professional Training Documentation

State recognized licensed practitioners need only provide the license number and the state in which they practice. Uploading diploma or record of training is optional. All others please provide diploma, record of training, and/or a certificate of completion. We love students . Please provide student ID from an established school. We recognize many schools do not have official ID's distributed. Email acceptance into a school or other forms of communication with the school will be accepted.

State

Kind of Practice

Number

Documentation of training

Optional: Tax Documentation

California Residents: to be eligible for tax-free sales, please complete and submit CDTFA-230 Form.

Resale certificate

How did you hear about us?

How did you hear from us - Additional details

Thank you for your application.

You will be notified after your account has been reviewed. If you have not created a basic account, you can do so now by clicking here.