MicroVet Diagnostics New Account Enrollment

New Account Enrollment

Name of MicroVet Diagnostics Account Rep

Company Name *

Billing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Date *

Delivery Address

Street Address

Street Address Line 2

City State

Zip Code Country

Business Hours:

	Open	Close
Monday
Tuesday
Wednesday
Thursday
Friday

Please provide credit card info to be used for initial purchase and retained for future purchases and charged at the time of order.

Card Type Card Number Expiration Date (MM/YY) Security #

All account terms are Net 15 days. Accounts with a balance exceeding payment terms are subject to a 1.5% finance charge. Account is responsible for all product charges, shipping charges and applicable sales tax. Unpaid account balalnces that require outside collection efforts will be responsible for any collection and/or legal fees. Signature acknowledges and agrees to terms of agreement, authorizes card information to be processed and stored, agrees to receive information and updates via email, and also represents a personal guarantee.

Print Name * Signature * Date *

How would you like to receive invoices? *

By Mail By E-mail Auto pay (Please provide credit card information above)

Special Delivery Instructions:

Primary Contact *

First Name Last Name

Alternate Contact

First Name Last Name

Phone Number *

Fax

Alternate Phone Number

Contact E-mail *

Updates, invoices, etc. will be sent here

Lab E-mail

Equipment updates and information will be sent here

Please read the Terms and Conditions

By initialing below, I acknowledge that I have read and agree to the above terms & conditions. *

Please verify that you are human *

Contact Information