SMPLTRAX | Next Generation Blockchain LIMS Software

Distributor/Business Name *

Enter Legal Distributor/Business Name on state issued license.

DBA (if applicable)

Enter DBA (if applicable).

Address *

Please Enter Street Address.

City *

Please Enter City

State *

Please Enter State

Zip Code *

Please Enter Zip Code

Hours of Operation

Enter hours of opearation (for pickup and contact purposes)

License No. (i.e. Distributor license)

Please applicable license no. (C11, C12, CCL, or CDPH)

Phone *

Please Enter Phone Number

First Name *

Please Enter First Name

Last Name *

Please Enter Last Name

Email *

Please Enter Email

Password *

Please Enter Password

Preferred Method of Contact *

Please select your preferred method of contact.

Your company role: (select all that apply)
  I am an owner of the company
  Sample pickups and/or answer batch questions
  Payment and/or invoicing

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