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e ~ ~ PETtrac'" Application 4. Pet Information -Pet #1 <br /> ld o Apply'Ibday! <br /> lsG ~ Enroll by mail or fax. Fill out and slgn application. Enclose coma-L Pet Name <br /> ~ payment. Uo not send cash. <br /> Illg,~ ~ Spemas (flag/Cat/Ilnrsr/Bird/Other) Brred <br /> is tl ? PLAN A: Multiple Pet Reglntry. Rne.losr, payment of 590.00 to <br /> x protect up to eight pets. Attach separate ,Berl, as needed. <br /> I~,~ m Cendrr VrniaNFpav Uem of R71Yh (Yraf/Month) Wmght (Ibs. <br /> a L I PLAN K: Single I'et Kegistry. Enclose $L-i00 per pet for e Ilfetuue Min riv i <br /> ulrr) m pct rrglstra6lon_ (ex 2 pets= $3000) Colortfdarkinge <br /> INFURMA'f10N f,HANf.H;: P;ucloso 50.00 (f~.x. ahauge of <br /> wt~ eddressl. Special Military rates available. Medicntmn <br /> Eat) ~ f' NEW MEMRF,k ? ALREAb~' A .MEMBER <br /> ;l vd ~ othor Data <br /> 7. Owner Information <br /> h e~ <br /> m Lao~t Nwnr Frost Sann• Middle IniWal Mmrorhip IDh (plrs~ee check fur eccuracyl <br /> ICf z <br /> 5 s <br /> i m hddrrv~ <br /> a 5. Pet Information -Pet #2 <br /> ~ m <br /> I;ity Ste Lr IR' Pet Name <br /> wr, <br /> (Isl ~ nonu•Phone N'm~t Phone Speclrs (BOg/Cat/Horse/Birds Ocher) BreoO <br /> "rl4 O <br /> p;~~ Gender Ncotcr/Spay flute n~ Birth fYear/Month) Weight Qhe <br /> I~, <br /> -l M/1' Y/N / <br /> ~~h8, m Color/Markings <br /> ~ e~ ~ 2. Alternate Contact <br /> Medmation <br /> fl0t m La,f NpoIP Fits 1. Namc Mldtllc Initial <br /> a <br /> m <br /> i8P address OUier Data <br /> <br /> ;hm <br /> Mleroclup IDN (pleaee check for arcuracp) <br /> Tlfl~ ~ City Stele Zq, <br /> ronl ~ ~~01°~ r~nane wort Pnmi,~ Make check pa able Lo AVID"' in the amount of $T 5 00 ter pet for <br /> the Single Pct Registry, ar $40.00 for the Multiple Pet Registry, or <br /> the m $6.00 for information change. <br /> ~ ~Pnn <br /> i PAYMENT`. ? Check or Money Order <br /> <br /> Dw ~ - CHARGE 11Y ? VISA ? MasterCeM <br /> fu m 3. VeterlnaClan/lmplanter InfOrmatlOn [ 7 Discover ? American Express <br /> 6e~t Name hli;vt Nance wnmlr Inlna~ Card # <br /> ~ p~.,r,i,ty Expiration Date <br /> _o AU'I'I10RIZATION <br /> ~ ,lri,~,,.ti, I acknewledgc that the above information is trot and correct. My <br /> ~ signs Wire authorizes the release oP this information and payment if <br /> m <br /> paying by credit card. <br /> z i <br /> ~.ip svnr F.~n <br /> x Signature Dale <br /> m <br /> ~ i°iu,r,~. i:ns PIIONI?_ 500-371-7505 ~ £300-33G-AVID • FAX: 909-737-8967 <br /> m <br /> E-mast I'CttPffi:@aoLcmn RF;V 3/f70 <br /> <br />