ProXtracts Intake Form

Please use this intake form to get started doing business with us. Ensure all fields are filled out correctly.

    First Name*

    Last Name*

    Your Role*

    Phone*

    Your Email*

    Company Name*

    Company Website

    Street Address*

    Suite

    City*

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    NY Cannabis License Number:

    Products or Services Sought*



    I am interested in something not listed above

    Do you need custom formulation?*



    How long have you been in business?*



    What is your company's revenue per year?*



    Human Verification