Fillable License Ownership Transfer Form (Triadex Services)

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License Ownership Transfer Form (Triadex Services)

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License Ownership Transfer Form
Complete this form if you are transferring ownership of a Covetrus Software Product.
All fields are required unless specifically marked as optional.
If you are the current owner of the license, please complete Part I.
If you are the new owner of the license, please complete Part II.
EFFECTIVE DATE:______________________
Part I – Current Owner’s Information
I am the current owner of the license identified. I am transferring all rights, title, and interest in and to the license to
own with respect to the product (including the right to use any prior version or upgrades) to the new owner, identified
below. The new owner has agreed to be bound by the terms of the product’s End User License Agreement / Service
Agreement which may be updated by Covetrus from time to time.
I understand that by signing and submitting the Transfer of Ownership, I am relinquishing all rights to the product and
my name will be eliminated from Covetrus’ customer records in connection with the product. If the transfer is being
completed on behalf of a company or other organization, I represent and warrant that I have the authority to sign this
transfer on behalf of the current registered owner.
Product(s) Being Transferred:
Practice Management Software
☐ Advantage+ ☐ Vetech Advantage ☐ AVImark ☐ DVM Manager ☐ eVetPractice
☐ ImproMed (Infinity) ☐ ImproMed Equine (TripleCrown)
Client Communication Services
☐ Rapport ☐ Vetstreet
Current Registered Owner:
Name(s)*: _______________________________________________________________________
Company Name: __________________________________________________________________
Company Address: _________________________________________________________________
Company Phone Number: ___________________________________________________________
Email Address: ____________________________________________________________________
Selling Owner’s Signature(s): _________________________________________________________
*If there are multiple partners who share ownership, all applicable names and signatures are required.
Part II – New Owner’s Information
I, the undersigned, acknowledge receipt of this software and documentation. By signing, I confirm that I have read the
End-Use License Agreement / Service Agreement included with the software package being transferred, which may be
updated by Covetrus from time to time, and that I agree to be bound by its terms. I understand that any outstanding
balances owed by the hospital will remain with the account.
New Registered Owner:
Name: * _________________________________________________________________
Company Name: __________________________________________________________
Company Address: _________________________________________________________
Company Phone Number: ___________________________________________________
General Email Address: _____________________________________________________
*If new owner is a corporation please list the name(s) of the individual(s) authorized to make changes in secure areas of
the program: ______________________________________________________________
Clinic Information:
Primary Clinic Contact: _________________________________________________
☐ (Optional) The clinic’s name, address or contact information needs to be changed as indicated below:
Business Name: _______________________________________________________ Optional
Business Phone Number: ________________________________________________ Optional
Email address: ________________________________________________________ Optional
Mailing Address: _______________________________________________________ Optional
Support Coverages (Practice Management Software Only):
By default, we will continue with the existing level of support coverage unless/until you make changes.
Client Communication Services:
By default, we will continue with the existing services unless/until you make changes.
If you want to be contacted to discuss the following client communication services which are available to you,
please indicate which one (optional).
☐ Rapport Subscription ☐ Vetstreet Subscription ☐ Postal Communications
Billing Information:
We need to have billing information on file which will be used to automatically pay for support coverage. You also have
the option to pay all of your Covetrus bills automatically with a credit card (all major credit cards accepted) or
Automated Clearing House (ACH) payment through a checking or savings account each month (US Accounts only.)
Check the box below if you would also like to sign up for auto pay for all Covetrus bills.
Please note - All invoicing is processed in USD.
☐ (Optional) I authorize Covetrus to use the below payment information to automatically charge ANY open
balance, for the clinic, at the point of sale. Note that the following fields are required even if you don't select
the authorization checkbox.
Billing Address: ____________________________________________________________
City, State, Zip: ____________________________________________________________
Billing Email Address: _______________________________________________________
Last 4 digits of credit card/bank account to be charged: ____________________________
(Upon receiving this completed form, a billing representative will contact you for the appropriate credit/ debit
information for the billing card on file.)
Name and Title: ____________________________________________________________
Contact Number: ___________________________________________________________
Purchasing Owner’s Signature: ________________________________________________
If you would like to receive confirmation that your change of ownership process has been successfully
completed, please provide your contact email address: _____________________________________
Please return the completed form to the license transfer department:
Email: US-CGSS_LicenseTransfer@covetrus.com
Fax: 866-365-7945
Or mail to the address below:
Address: ATTN License Transfer Dept.
3800 Horizon Blvd. Suite 201
Trevose, PA, 19053
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License Ownership Transfer Form (Triadex Services)

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Completed 3 November 2021

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