Customer Testing Supply Online Order Form

For A Mail-In Version of This Form For Microsoft Excel, Click Here
For A Mail-In Version of This Form In A PDF File (Adobe Reader), Click Here
Farm/Ranch Name: Phone:( ) -
Contact Person: Cell (Alt. Phone):( ) -

Address:

Fax:( ) -
City: Email:
State: Zip (Postal) Code:

Testing Supplies Ordered

Blood Cards ($1.00 per card) Num. cards: Total Cost (Blood Cards):
Hair Cards ($1.00 per card) Num. cards: Total Cost (Hair Cards):
Sarstedt Syringes ($1.00 per unit)
(contain anticoagulant)		 Num. cards: Total Cost (Syringes):
    Postage & Handling Cost
(See Chart Below)
    Total Cost
We do our very best to process and mail testing supplies on the same day they are ordered. We sell the testing cards and syringes at our cost, therefore it is necessary to add a minimal fee for shipping and handling. Please refer to the chart below to determine your shipping/handling fee.

Postage/Handling Fee Chart Fee
1-10 testing cards  First Class Mail $2.00
11-20 testing cards First Class Mail $3.00
21-30 testing cards First Class Mail $4.00
30+ testing cards (shipped in priority env.) $4.95
Sarstedt Syrings (shipped in priority box) $4.95
Priority Shipping (any number of cards) $4.95
Express Shipping (any number of cards) $17.50

Payment Information

Visa
Mastercard
Check/Money Order

Card Number:
- - -
Name Exactly as it Appears on Card: Expiration (MM/YYYY) /

Address on Card:


City on Card:

State: Zip:

Security Code (Last 3 Digits on Back of Card)

If paying by card, please complete an "electronic signature" by entering your full name on the line below. This process is as legally binding as a handwritten signature:
I authorize Stockman's Resource Center LLC to process charges to the above account.
I have read and acknowledge the terms and conditions set forth by Stockman's Resource Center LLC.
I certify that the information provided on this form is true and accurate to the best of my knowledge.

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