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Register for a New Account

Fill out the following form to request an account on the PacCana website to allow you to purchase. Once this form has been filled out, PacCana will review your account and notify you when your account is active.

Company / Name

Please enter either a company name or a first and last name (or both).

Company *
First Name *
Last Name *
Title

Login Information

This information will be used to access your account. Your username will be assigned by PacCana. The passphrase will be used to recover your password if you forget it.

Password *
Confirm Password *

Contact Info

Email *
Phone 1 * Example: 434-343-6545
Phone 2 Example: 434-343-6545
Fax Example: 434-343-6545

Shipping Address

This address will be used as your default shipping address, although it can be changed before completing your order.

Shipping Address 1 *
Shipping Address 2
Shipping City *
Shipping Province/State *
Shipping Postal/Zip Code *
Shipping Country *

Billing Address

This address will be used as your default billing address, although it can be changed before completing your order.

Billing Address 1 *
Billing Address 2
Billing City *
Billing Province/State *
Billing Postal/Zip Code *
Billing Country *

Additional Information

US Federal Tax Number
GST Number

Enter any notes you think would help PacCana when approving your account.


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