AM and NH Form Customer Information Form Oct 2010 by Fp05N61

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									                                            2371 330th Street, Eddyville, IA 52553
                                           Office 641-969-4111         Fax 641-969-4600
                                                   stockmansresource@hotmail.com
                                                     www.stockmansresource.com

                                                 Customer Information Form
 Farm/Ranch Name
  Contact Person
        Address
             City
           State                                                                 Zip
          Phone                                                                  Cell
             Fax                                                                 Email
* * * * * * * * * * * * * * * * * * * * * * * * * * * * *                        * * * * * * * * * * *
                                   Choose your test or testing combination
                      We accept blood cards, hair cards, semen or whole blood (purple top)
                                                                     Price           Number of
                                                                  Per Sample         Samples                    Cost
AM, NH or CA                                                        $20.00
Any Combination of 2 tests; AM, NH Or CA                             $33.00
Any Combination of 3 tests; AM, NH or CA                             $45.00
OS - Red Angus; Whole Blood, blood or hair card only                 $20.00
Additional Fee for Whole Blood Samples                                $1.00
Priority Shipping to the Lab                                         $4.95
Express Shipping to the Lab                                         $17.50
Samples are shipped to the lab via First Class mail, generally on the date of                  Total Due
receipt, for no charge unless "Priority" or "Express" shipping is requested.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
                                                        Payment Information
      Payment Method                     (Circle One)                  Check Money Order Visa or Master Card
                                                         Credit Card Informaton
        Credit Card Number
   Name on Card                                                              Sec. Code__________
 Address on Card
             City                                           State_______     Zip
       Exp. Date                                  Signature
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
                                                        ACKNOWLEDGMENT
           I certify that the information provided on this form is accurate, and I acknowledge that I have read and agree to
           the Terms and Conditions included with this form and/or as printed on the Stockman's Resource Center website.
                                   Owner or Authorized Representative Signature

                                                                   Date Signed

								
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