American Eagle Instruments, Inc

Please complete the form below (be sure to complete all required fields), then click "Complete Sign-Up" to submit your information. Your sign-up can include an opening order (but it isn't required), which can be either a standard order or the Member Exclusive Offer (see below for details), or both. Thank you for your interest in the xpRewards™ program!

Contact Information: (all contact info fields must be filled)

Full Name:

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email:

Address (with Apt.# or Suite, if applicable):

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Referred By:

Member Exclusive Offers (limited to one each - see our Online Catalog for product codes):

Infinitip™ Magneto Ultrasonic Insert - $100 ($34.50 savings) - Product Code:

XP Technology™ instrument - $25 ($21.95 savings) - Product Code:

Preferred Dealer (required)

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Note: You must have an existing account with the dealer you select for your order to be processed.

Dealer Account #:

Please add any additional instruments to your order below:

(Must provide full, correct product codes - see our Online Catalog for product codes)

Include quantity in parentheses after the product code. Example: "AEG1-2XPX (5)"