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NetLink Form

Nebraska Cattleman

1520 Prairie Drive • PO Box 938 • Worthington, MN 56187-0938 • Phone: 1-800-220-2522 / 507-372-7779 • Fax: 507-372-2565

NetLink Form

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NetLink Enrollment Form

Please fill in the following information to enroll in the NetLink program from Newport Laboratories. The information you provide in this form is confidential and will be handled by a Newport Laboratories representative in accordance with our Privacy Policy. All information volunteered in this form will be kept confidential by Newport Laboratories. Your information will not be distributed to other companies without your consent.

NOTE: Fields marked with an asterisk * are Required.

Personal Information

First Name*

Last Name*

Please enter the name of the clinic you work for. (Required Field)

Clinic Name*

Telephone

xxx-xxx-xxxx

Please enter your Fax Number (Optional).

Fax

xxx-xxx-xxxx

Email Address*

bob@example.com

Shipping Address

Please enter your shipping street address (Required Field).

Address Line 1*

Please enter P.O. Box, Apt or Suite Number (Optional)

Address Line 2

City*

State*

Zip Code*

Billing Address

My Billing Address is the same as my Shipping Address.

Please enter your billing street address (Required Field).

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Account Information

Newport Account Manager

(Please enter the first and last name of your Newport Laboratories Account Manager.)

New Members - 50,000 Dose Minimum

Renewing Members - 15% Growth over 2007 actually purchased doses

Please enter the amount of doses you purhcased in 2007, or enter "0" (zero) if you are a new member.

Amount of Doses Purchased in 2007

(enter "0" if new member).

Please enter the amount of doses you plan to purchase for 2008.

I/we agree to participate with the following amount of doses for the year of 2008:

Please enter the first and last name of your Purchasing Agent, or your Purchase Order Number.

P.O. Number Contract or Purchasing Agent

(First and Last Name please)

Enroll Today and Receive the Following Bonuses!

FREE Swine Disease Diagnostic Manual.
(English or Spanish Edition)
24 FREE Spiral-Top Notebooks (5½" x 8") personalized with your clinic information.
Newport Diagnostic Laboratory Accession Fee waived from January 1, 2008 through March 31, 2008.
FREE Gene Sequencing from Newport Diagnostic Laboratory.

Enroll in Electronic Diagnostic Online Reporting (EDOR)

Please check this box if you would like to enroll in EDOR.

I would also like to enroll in EDOR (Electronic Diagnostic Online Reporting)