Fillable Reunite Microchip Registration Form - American Kennel Club printable pdf download

Reunite Microchip Registration Form - American Kennel Club

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AKC R eunite M icrochip R egistration

Pet I nformation

Microchip # : _ _______________________________

Pet N ame: _ __________________________________

Or p lace b arcode s ticker h ere.

Species: ☐ D og ☐ C at ☐ O ther: _ _______________

Breed: _ _____________________________________

☐ M ale ☐ F emale S pay/Neutered: ☐ Y es ☐ N o

Pet’s V eterinarian

Date o f B irth: _ _______________________________

Name o f C linic: _ ______________________________

Color/Markings: _ _____________________________

Phone: _ ____________________________________

Registry ( if a pplicable): ☐ A KC ☐ O ther: _ _________

Registration # ( if a pplicable): _ ___________________

Primary C ontact I nformation

Communication P references

First N ame: _ _________________________________

Periodically, A KC R eunite w ill s end y ou i nformation

Last N ame: _ _________________________________

directly r elated t o y our p et’s e nrollment. P lease c heck

Address: _ ___________________________________

the i nformation y ou D O N OT w ant t o r eceive:

City: _ ____________________ S tate: _ ____________

☐ P romotions/ n ews f rom A KC R eunite

Zip: _ ______________ C ountry: _ ________________

☐ E -‐mail p romotions/news f rom A KC R eunite

Home P hone: _ _______________________________

☐ S hare m y i nformation w ith t hird p arties f or p et

Work P hone: _ _______________________________

related o ffers.

Mobile P hone: _ ______________________________

Text M essage E -‐mail: _ _________________________

Note: E nrollment i n A KC R eunite w ill h elp t o e nsure s afe

E-‐Mail: _ _____________________________________

return o f y our p et

Alternate C ontact I nformation

First N ame: _ _________________________________

Last N ame: _ _________________________________

Home P hone: _ _______________________________

Work P hone: _ ________________________________

Mobile P hone: _ ______________________________

E-‐Mail: _ _____________________________________

Note: E nrollment i n A KC R eunite w ill h elp e nsure s afe r eturn o f y our p et w hen f ound, b ut d oes n ot s ignify o wnership. P rices s ubject t o c hange.

AKC R eunite 8 051 A rco C orporate D rive, S uite 2 00 R aleigh, N C 2 7617 F ax 9 19-‐816-‐3828 w