Legal Entity Name	Phone Number
* Required	* Required
DBA	EIN Tax ID Number
Business Start Date
* Required	* Required
Address Line 1
* Required
Address Line 2
City State Zip Code * Required * Required * Required
Contact Name	E-mail Address
* Required	* Required Invalid Email Format

Laboratory Name	Lab Account Number
* Required
Bill Through Lab	Ship to Account Number
LAB
* Required

Which, if any, doctors alliance do you belong to.	Default Shipping Method
	* Default ship method are required

Name	District Manager
* Required	* Required
E-mail Address	Territory Number
* Required Invalid Email Format	* Required
Phone Number	District Number
* Required	* Required

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