First Name |
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Last Name |
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Farm Name |
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E-mail Address |
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Phone Number |
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FAX Number |
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(Address information must match credit card entered below.) |
Mailing Address 1 |
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Mailing Address 2 |
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Mailing Address City |
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Mailing Address State |
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Mailing Address ZIP |
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Enter expedited delivery shipping address -
where you want your analysis to be delievered.
Check here if same as Mailing Address above. |
Shipping Address 1
(No P.O. Boxes) |
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Shipping Address 2 |
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Shipping Address City |
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Shipping Address State |
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Shipping Address ZIP |
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You may only order a report for one broodmare at a time. If you have more than one broodmare you wish to analyze, please complete several copies of this form and submit each order separately. |
Mare Information |
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Name of Mare |
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Sire |
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Dam/Damsire |
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Additional Copies Desired |
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Billing Information |
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Credit Card Type |
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Credit Card Number |
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Expiration Date (Mo/Yr) |
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Remember - Credit card account records must match mailing address entered above. |
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Anything else? |
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If you have any comments or anything further on your mind, please don't hesitate to tell us what else we need to know:
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