WE DELIVER HIGH-QUALITY CRAFT

Register Dispensary Account

Full LEGAL Business Name(Required)

Main Contact Name(Required)

First Last

Retail Store License Number(Required)

Email(Required)

Phone(Required)

PST#(Required)

Shipping Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

No P.O. Box

I declare that the information in this application is true and correct in every aspect.

I authorize Supernova Farms Inc. to debit my credit card for purchases.

Name(Required)

First Last

Signature(Required)

Payment Card Details

*Secured Transaction & Encryption Provided via Chase Bank. Orders will only be processed after you fill out our order form here.*

Full Name On Credit Card

Credit Card Number

Credit Card Expiry Date

Credit Card Type

Visa

MasterCard

Postal Code

Signature