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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:
 _____________________________________________________
Other Responsible Party:
 _____________________________________________________
Street Address:
 _____________________________________________________    
City:
 _______________________________
State:
 _____    
Zip:
 __________        
           
Phone #
(______)_______-___________
 
      
Cell #
(______)_______-___________
 
      
 E Mail: __________________________      
 
          
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:
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Age:
 ____
Name:
 _________________
Breed:
 _____________
Sex:
 __________
Color:
 __________
Type:
 _________
Age:
 ____
Name:
 _________________
Breed:
 _____________
Sex:
 __________
Color:
 __________
Type:
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Age:
 ____
 
                      
__ 1 pet $79/yr
__2 pets $99/yr
__3 to 6 pets $119/ yr
__7 or more pets $149/yr

Select method of payment: Master Card, Visa, Discover Card, American Express or check
(please make checks payable to American Pet Care Plan)
Credit Card Number:
 _________________________________  
Expiration Date:
 ___/___/______  
 
  
3-Digit Card Security Code:
 ______________   
I hereby authorize American Pet Care Plan LLC 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 LLC
1144 Juniper Road
Taos, NM. 87571