American Pet Care Plan Mail In Enrollment Form

 

 
Enrollment Membership Type
 
New :
_________    
Renewal:
_________    
       
Owner's Information
       
Today's Date:
___/___/______ format dd:mm:yyyy    
Owner's Name:
____________________________________________________________ first and last name
Other Responsible Party:
____________________________________________________________ first and last name
           
Home Address
           
Street Address:
____________________________________________________________    
City:
_______________________________
State
_____    
ZIP:
__________        
           
CONTACT INFORMATION
 
Area Code:
(______) Phone #_______-___________
 
     
Area Code:
(______) Cell # _______-___________
 
     
           
E Mail:
_______________________________        
 
Choose Your Provider
 
Provider's Name::
Referred By:
________________________________    
 
 

 

 
Pet Information
 
                     
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
Name:
_________________
Breed:
_____________
Sex:
__________
Color:
__________
Type:
_________
Age:
____
 
                     
                       
                       
 
__ 1 pet $69/yr
__2 pets $89/yr
__3 to 6 pets $109/ yr
__7 or more pets $139/yr

Select method of payment: Master Card, Visa, Discover Card or check
(please make checks payable to American Pet Care Plan)

Credit Card Number:
____________________________________________________________________________________
Expiration Date:
___/___/______
3-Digit Code from reverse side of credit card
_______________
I hereby authorize American Pet Care Plan to charge my credit card account
thereby enrolling me in the services of American Pet Care Plan.
Signature:
_____________________________
Date:
___/___/______
       
Please allow 3-4 weeks for receipt of membership packet. Print application and PayPal confirmation to use as proof of membership, if needed, on first visit after enrolling or renewing. Veterinarians will be notified of all clients enrolled on a monthly basis..
 
Please print this form and fill in all required information. Attach payment if paying by check.
If paying by credit card your transaction will be processed through PayPal Secured online services.

Please mail completed application and payment to:

American Pet Care Plan
7904 E. Chaparral Rd., #110-470
Scottsdale, AZ 85250