Dealer / Veterinarian Registration Form

“Welcome to the EquiCareRx series of programs designed specifically for veterinarians. In order to gain access we ask that you fill out the form below or email us at: for more information. We look forward to helping you.”

Company Information

Billing Information (if different)

If non taxable, complete Resale Certificate (separate form)

Owner/Officer Information

Trade References

Bank Reference

Payment Information (to be kept in strict confidence)

Dealer Acknowledgement

The applicant authorizes EnviroEquine LLC to obtain a written or oral credit report and further authorizes any bank or commercial business to give any and all necessary information to the creditor, which will assist creditor in the credit investigation. The applicant also authorizes the creditor to reinvestigate the applicant's status from time to time as the creditor deems necessary. In collecting sum due as part of any credit extended on the basis of this application, I (we) agree to pay reasonable cost and expenses should legal recourse become necessary, including all attorney fees and costs incurred to enforce payment.