Microchip Register Now Official Form

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The Buddy System

Shelters & Care Givers

Do Something Wonderful for Your Pet!

• Any type of microchip can be registered below. Or you can register by phone!

1. Enter owner and pet information as you want it to appear on your Certificate.
     Please check accuracy and spelling.

2.  After you activate, you will receive by mail:

     Confirmation Letter, Certificate, Collar Tag and Wallet Card

3.  SAVE! Special price - $19.95 for life (regular cost is $24.95). No annual fee.
No charge for updates or changes.

MICROCHIP REGISTRATION FORM

Owner's Information
First Name: (required)	Last Name: (required)		Middle Initial:
Mailing Address: (required)
City: (required)	State: (required)	Country: (required)	Zip/Postal Code: (required)
Home Phone: (required)	Secondary Phone:
Email Address: (required)

Alternate Contact
First Name:	Last Name:
Home Phone:	Secondary Phone:

Veterinarian or Facility
First Name:	Last Name:
Facility:
Address:
City:	State:	Country:	Zip/Postal Code:
Phone:	Email Address:

Pet Information
Name:	Species: (required)	Breed:
Date of Birth:	Gender: (required)	Provider Code: (if available)
Color/markings: (required)
Microchip ID Number: (required) IMPORTANT Microchips can contain the number 0, but will never contain the letter O

Acceptance:
Signature: By entering my name in the box below I testify that the information contained herein is true and correct. My signature authorizes the release of this information in the best interests of the pet. (required)
Terms and Conditions:
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Agree (I have read, understand, and agree to the terms and conditions of use.) (required) To avoid duplicate registration, VERIFY all information BEFORE adding to cart.

If you have an Activation Card (not required), locate your
pet's microchip number on the back of the card.
See below.

Business office hours: 9-5 CST Monday - Friday
Phone: (800) 434-2843 Fax: (985) 796-1531
SEND EMAIL
Microchip ID Systems, Inc. - Registration Division
81447 Highway 25 Folsom, LA 70437

♦ NOTE ♦
THERE ARE NO SHIPPING OR HANDLING FEES ON
MICROCHIP REGISTRATIONS.

After you register, use your coupon code!
SAVE 10%
ON EVERYTHING IN THE STORE!

At Checkout
ENTER CODE: TAKE10
♦