PREMIUM DISPENSARY APPLICATION

*Fill out Application for FREE Screen or Call (855)763-2288

Location Name*
How many patients do you serve per day?*
How many members in your Collective?*
Location Type*
Location Hours*


Location Contact Name*
Main Contact Phone Number For Install*
Location Address*


Mailing Address (If different than location address)
Website*
Email Address*
Message
Representative*



Do you have a Guest Wifi Network?*
YesNo



Agree to Location(s) Agreement*
YesNo