Tmp - Virginia Equine Imaging - In the Plains, Virginia

Date of Pre-Purchase Exam

Intended Use/ Level of Horse: *

Horse Name

Age

Breed

Sex

Color

Buyer Name

Seller Name

Buyer Address *

Buyer Address

City

State/Province

Zip/Postal

Country

Phone

Cell Phone

Fax

Name on Credit Card

Credit Card Number

CVV / CCID (security code) *

Credit Card Expiration Date

Note: It is a VEI policy to have credit card information prior to prepurchase examination date. Your credit card will be debited at the end of the day that the horse was discharged, unless you prefer to pay by check in person at the time of the discharge. By signing this information form, you authorize such a credit card debit. If you will be sending a representative or agent instead you will be expected to pay for all financial decisions made on your behalf by the representative or agent (trainers, veterinarians, etc.) *

I agree

Signature *