Application for The Doe Report Affiliate Program




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11/20/08

Application Form for The Doe Report Affiliate Program

Please supply your contact information and tell us about your site.

Contact Information
*Personal Title:
*First Name:
*Last Name:
*Email:
*Phone:
Fax:
*Organization:

Payment Information
*Pay To:
*Street:

*Zip:

Site Information
*Site Name:
*Site Address:
*Site Type:
*Briefly describe your site, its purpose, and the approximate number of visitors it has per month:


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	(Please note: Your email address will serve as your login.)
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By submitting this Application Form, I agree that I have read, understand and agree to abide by the terms of the Affiliate Agreement.

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Nucleus Address: 1275 Shiloh Road N.W. • Suite 3130 • Kennesaw, Georgia 30144
Phone: (800) 338-5954 • E-Mail: service@doereport.com

All material ©1999 - 2008 Nucleus Medical Art Inc. All rights reserved.

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Medical Legal Art creates medical demonstrative evidence (medical illustrations, drawings, pictures, graphics, charts, medical animations, anatomical models, and interactive presentations) for use during legal proceedings, including research, demand letters, client conferences, depositions, arbitrations, mediations, settlement conferences, mock jury trials and for use in the courtroom. We do not provide legal or medical advice. If you have legal questions, you should find a lawyer with whom you can discuss your case issues. If you have medical questions, you should seek the advice of a healthcare provider.