Register – Cinden Group Of Pharmacies

Wholesaler Registration

"*" indicates required fields

Name*

First Last

Email*

Password*

Enter Password Confirm Password

Name of Licensed Health Care Professional*

Professional Title*

Province of Issued License/Certificate*

License/Certificate Number*

Expiration Date*

Practice/Business Name*

PRACTICE/BUSINESS LOCATION*

Street Address Address Line 2 City Province Postal Code

BILLING ADDRESS (If different from above)*

Yes

BILLING ADDRESS (If different from above)*

Street Address Address Line 2 City Province Postal Code

CONTACT INFORMATION*

Name of Primary Contact

Primary Telephone Number*

Fax Number

Business Email Address*

Would you like to subscribe to Cinden email communications?

Yes

Website

Will you be promoting Cinden products through this website?

Yes

Please ensure that all required documents are signed and dated. (All required forms can be found below)

CinDen Wholesale Acknowledgement Agreement 2022 (signed)*

Max. file size: 512 MB.

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