New Customer Registration| Lake Immunogenics

Billing Information

Company Name:*

Contact Name:*

Title:*

Address:*

Phone:*

Fax:

Email:*

Referred By:

Tax Exempt:*

Yes

No

County:

For New York State customers only.

Upload Tax Exempt Form or Resale Certificate:*

Please upload a copy of your tax exempt form or resale certificate.

Credit Card Information

Please call 1-800-648-9990 with your credit card number.

Shipping Information

Shipping Address:*

Different from Billing Address

Same as Above

Shipping Address Type:*

This is a residential shipping address

This is a commercial shipping address

Company Name:*

Contact Name:*

Title:*

Address:

Phone:*

Fax:

Email:*

Veterinarian Information

If you are a Veterinarian or a Veterinarian's Office, please complete the information below.
Required if purchasing USDA Licensed Products or giving Client Authorization.

Are you a Veterinarian or Veterinarian's Office?*

Yes

No

Veterinarian’s Name:*

Veterinarian’s License No:*

State:*

Expiration:*

Veterinarian’s Signature:*

Reset

Client Authorization:

The above information is submitted for the purpose of authorizing sale directly to my client named above.

Authorized Signature & Date

Printed Name:*

Email:*

Authorized Signature:*

Reset

Date:*

New Customer Registration

Billing Information

Credit Card Information

Shipping Information

Veterinarian Information

Authorized Signature & Date

Partner with Lake Immunogenics

Partner with
Lake Immunogenics