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Automatic Badge Replacement for 1 year

Fully automated, computer generated report

Control badge provided at no additional cost

Reply envelope to send badges in for testing

myTLDaccount service for instant online access to your account

	* denotes required fields
Dealer Account Number
Dealer/Account Representative E-Mail
Dealer P.O. Number
Clinic P.O. Number
*Clinic Name
Doctor
*Primary Contact
*Address
*City
*State
*Zip Code
*Clinic Phone Number
Clinic Fax Number :
*E-Mail
*Start My Contact On
*Frequency of Service :
*Type of Service :
*Yes, I want automatic annual renewal :

Add the Following Employees:

*Employee Name

*SS/Employee ID

*DOB (XX/XX/XXXX)

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