SAMNet Signup Form for Veterans

Thank you for your interest in the SAMNet Vets program. Please complete this form and choose “submit” when you are done. After you have submitted your application, an email will be sent to the VIST professional listed on the form. The VIST professional should print out and sign the form contained in the email, and fax to Serotek within 30 days.

Are you a veteran with an existing Serotek account?

Veteran's first name:
Veteran's last name:
The user name that you enter below will be the basis of the veteran's email address. For example, if you enter "joe", then the veteran's email address will be "joe@samobile.net".
Desired user name:
Veteran's password (choose at least 6 characters):
Veteran's password (again):
Veteran's home address line 1:
Veteran's home address line 2 (if any):
Veteran's city:
Veteran's state:
Veteran's zip code:
Veteran's home phone:
Veteran's existing email address (if any):
VIST professional's first name:
VIST professional's last name:
VIST professional's organization:
Organization address line 1:
Organization address line 2 (if any):
Organization city:
Organization state:
Organization zip code:
VIST professional's contact phone number:
Note that the email address you enter below will be used to send important documentation which must be submitted for program eligibility.
VIST professional's email address:

Enter the username of the existing account:
Or enter the account number of the existing account:
And enter the password or PIN of the existing account: