Nikon Affiliation Form
1. Member Information
Account Name
Doctor/Owner Name
Address
Street Address
City
State
Zip
Work Phone
2. Account Information
Nikon Account Number (if not currently an Nikon customer leave blank)
Written Notice Consent
Nikon may change a Member's designation of its alliance of choice to another alliance upon receipt of written notification or instructions (including electronic) directly from such Member. Nikon shall confirm all changes to a Member's alliance of choice designation directly with such Member.
By completing this form, you are authorizing Mercantile to submit an affiliation request for Nikon. Doing so will affiliate the account number above with Mercantile pricing and benefits. If you do not have an account number, a Mercantile representative will reach out to you directly to help set one up for you.
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