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REGISTER YOUR ORGANIZATION
Organization's Registration Form
Please complete and submit this form
*
Indicates required field
1. Name of the Organization
*
2. Is this Organization/Ministry based in the United States?
*
Yes
No
4. Organization's official address
*
Line 1
Line 2
City
State
Zip Code
Country
5. Organization's phone
*
3. Is this Organization/Ministry a 501(c)(3)?
*
Yes
No
6. Contact person's name
*
First
Last
7. Contact person's position in the organization
*
8. Contact person's phone
*
9. Contact person's email
*
10. Name of Head Physician for Organization
*
First
Last
11. Head Physician's Address
*
Line 1
Line 2
City
State
Zip Code
Country
12. Head Physician's phone
*
13. Head Physician's email
*
14. U.S. State Head Physician is licensed in
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
15. License #
*
16. Expiration date
*
17. Country where supplies will be used
*
18. City and State where supplies will be used
*
19. Date & duration when supplies will be used
*
20. Other information
*
Submit
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