ACCT-C PILOT
UserName *
Email *
Phone Number *
Company Name
Select Role*
Admin
Owner
staff
Customer
Store Owner
Name *
Select customer group*
Regular
Tax Number
Address *
City *
State
Postal Code
Country
Select Biller*
owner's name here (08028401660 08036948417 08075277206)
Lauham Pharmacy Branch (08036948417 08177325750)
Select Warehouse*
Lauham Pharmacy
Lauham Store
Password *
Confirm Password *
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