Are you affiliated with another Veterinary Group (Or under a holding company?) *

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No

Address *

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Type of Company (pick one) *

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Type of Industry *

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Animal Clinic/Hospital

Farm/Producer

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Veterinary Practice/Consultant

Species served *

SWINE

CATTLE

DEER

RABBITS

COMPANION

BILLING ADDRESS *

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ACCOUNT PAYABLE CONTACT *

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ACCOUNTS PAYABLE CONTACT INFO (if different than Billing)

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Bank accounts (check all that apply) *

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Address *

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Address *

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