Please complete the form on this page to begin the registration process. Fields marked with an asterisk (*) are required. Upon completion of this form, a representative will contact you to complete your application.
Prior to activating your account, we require you to provide the following:
- A copy of your active State Board License
- A copy of your active DEA License if applicable
- A completed credit application:
Download Credit Application
You may submit the credit application using any of these methods:
- Email: email@example.com
- Fax: 800-687-8902
- Mail: Attn: New Account Registration
201 W. 5th Street, Suite 1250
Austin, TX 78701
For more information, please email us at firstname.lastname@example.org or call us at (800) 423 6967.