New West Coast Cure Client Form

  • Name of purchaser (First & Last)
  • What is your legal business name
  • Are you doing business as another name?
  • Who is the primary contact that will be receiving the order?
  • What is the best email to reach you at?
  • What is the best number to call for deliveries?
  • The delivery address should be whats shown on your license
  • Please select 1 or more of the licenses
  • What is your retail license number?
  • Whats the name of your sales rep?
  • Whats the URL of your website?
  • Accepted file types: jpg, gif, png, doc, docx, rtf, .
    Please upload a copy of your sellers permit and a copy of your license