Wholesale Account Application: License Upload

Name of Licensed Healthcare Professional or Business Owner:*
First Last
Healthcare License, Business License and/or Resale Certificate*
Drop files here or

Accepted file types: pdf, jpg, jpeg, png.
Use .pdf, .jpg, or .png file type.
State of Issued License/Certificate*
License/Certificate Number (If Applicable)
License Expiration Date (If Applicable)
Date Format: MM slash DD slash YYYY
Email Address:*
Would you like to subscribe to AMMD email communications?*
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.

All of the documents below are required before we can open your account. Please ensure that all required documents are signed, dated and filled out in their entirety to avoid any unnecessary delays in our review process. If any of these documents are missing or incomplete, your wholesale account cannot be established. Once your application is approved, the following documents will be emailed to you for completion:

Terms and Conditions
Return Policy
Reseller and MAP agreement