Provision New Institution - Ligarion Platform

Institution Information

Institution or Program Name *

The name as it will appear in the application

Legal Name *

Used in Stripe and for all billing purposes

Tax ID / EIN

Website

Select Plan *

Choose the subscription plan for this institution

Primary Email *

Primary Phone *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

An invitation email will be sent to the institution manager to complete their account setup.

First Name *

Last Name *

Email *

The invitation email will be sent to this address

Phone

Stripe Customer

A Stripe customer will be created automatically when you submit this form and linked to the institution.

Payment Status *

Account will be inactive until payment is received

Internal Testing Account (100% discount coupon)

Check this box to apply a 100% discount coupon for internal testing purposes. This will create a free subscription.

Internal Notes