Buying Group Registration

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You need your internal Buying Group member ID to register as part of a Buying Group, not your Labtician customer number.
If you do not have one, please register as a retail customer.

   

* Mandatory

  Title:

 

 

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* First Name:

A value is required.

  * Last Name:

A value is required.

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* Buying Group:

  * Please Specify:   

A value is required.

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  Primary Specialty:

    Subspecialty:

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  Registration #:

Pharmacist # is required.

   
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  Labtician Cust #'s:

 

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* Member Cust #'s:

  Access Code:

   

  Select Courier:

    Courier Account #:

A value is required.

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* Clinic/Office:

A value is required.

 

A value is required.

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* Address:

A value is required.

    Address 2

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* City:

A value is required.

  * Province:

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* Postal Code:

A value is required.Invalid format.

  * Country:

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* Telephone:

A value is required.Invalid format.

    Ext:

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  Fax:

   
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  Website:

      

 

 

* Email:

A value is required.Invalid format.

  * Confirm Email:

A value is required.Emails don't match.

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* Password:

A value is required.Exceeded maximum number of characters.[6-14 Chars]Minimum number of characters not met.The password doesn't meet the specified strength.[6-14 Chars,min 1 Capital and Number]

  * Confirm Password:

A value is required.passwords don't match.

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* Send Invoice to: (Check one only)

 

Purchaser's Email As Above

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Accounts Payable Email:

  A value is required.Invalid format.
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Confirm Email:

  A value is required.The values don't match.
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Language Preference:   English French

 

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No , I do not wish to receive periodic information on promotions and special offers from Labtician Ophthalmics, Inc. via email.


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