Commercial Account Details

Account Registration Type * Retail Account Registration Commercial Account Registration Reseller Account Registration Tax Exempt Account Registration Government Account Registration RX Authorized Account Registration Please choose the account which best matches your intended use of our platform. Certain accounts will receive specific benefits and/or access to more features on our systems. For tax exempt and commercial applications, we do request documentation. For reseller accounts, you must reach out to reseller@lac.us with bank statements or a business proposal. Please ensure to always reference your account number.

Bank statements * Please provide three latest bank statements in a single file in .pdf, .jpg, .png, or .zip format

501(c) certification * Please upload 501(c) certification or other non-taxable organization document in a single file in .pdf, .jpg, .png, or .zip format

GS Level *

Rx Authorized Account * We require your license number to match HIPPA complaint databases for the address of record for the licensed person

Organization Name *

Organization Website *