Registration Form

For Canadian Retailers that have active accounts with Organika®.

This registration is a request. Upon confirmation of account details, you will be sent a username and password.

Read and review our Retailer Portal Terms of Use Agreement. Your acceptance of this agreement is required for completion of this form and use of the portal.

*Account #:
*First Name:
*Last Name:
*Sales Rep:
 
*Store Name:
Store Number:
*Address Line 1:
Address Line 2:
 Store Type:
*City:
*Province:
*Postal Code:
 Number of Staff:
 
*Email:
 Bus. Phone #:
 Cell:
 Bus. Fax #:
 
*I have read and agree to the Terms of Use agreement.
Please sign me up for Organika's Retailer Newsletter.
* Required Fields