Support Form Letter

							                                         Support Form Letter

Clinic Name:              _____________________________________

Address:                  _____________________________________

                          _____________________________________

Clinic Email address: _____________________________________


I, (we) agree with the priority statement: “To encourage and promote the pharmaceutical industry
to restructure drug rebate and/or pricing systems to Veterinarians across Canada, which does not
empower a few retailing companies the ability to gain drug sale clientele based solely on
discriminatory pricing.”


Veterinary Signatures:


________________________              _________________________                 ________________________
           Print name                               Signature                       (Personal email if necessary)




________________________              _________________________                 ________________________
           Print name                               Signature                       (Personal email if necessary)




________________________              _________________________                 ________________________
           Print name                               Signature                       (Personal email if necessary)




________________________              _________________________                 ________________________
           Print name                               Signature                       (Personal email if necessary)


Date signed: ___________________________

Return to: Bob Bellamy

Please check the buying group that you purchase the majority of product from:
AVP ___ VP___ Midwest___ WDDC____

Via Fax #: 306-694-1920