Pet Chip Registry, USA

P.O. Box 82952 Tampa, FL 33682

www.PetChipRegistry-us.info Single Pet Microchip Registration $19.95

Limited Time: Lifetime Registration with No Annual Fee.

Register your pet’s microchip and secure your position within the National Database. Please complete this section if this is a TRANSFER or if the microchip was implanted by the previous owner of your pet. If you do not have this information, you can also leave this section blank.

This pet was obtained from (Previous owner): Date of ownership transfer (or approximate date):

Previous owners address: City: State: Zip:

Previous owner’s phone number: Previous owner’s signature:

Please visit your account online at www.PetChipRegistry-us.info to make sure that all of your contact information has been recorded correctly. Please be sure to keep your contact information current. You can change your contact information at any time. Be sure to send in your application today to have your pet protected as soon as possible. _________________________________________________________________________________________

It is suggested that you add a photo of your pet to your account in the near future.

You can add a photo to your account by visiting your account page at www.PetChipRegistry-us.info 1

Print Your Pet’s Microchip Number in Boxes Below

Pet type: Breed: Color: Sex: D.O. B:

Type of microchip if known: Pet’s name: Is there a reward offered if found? Y N

Owner: Co owner:

Address: City: State: Zip:

Owner’s emergency phone number: Friend or family member ‘s name

*Mandatory* Email address: Friend or family number’s phone number:

Does this pet have a medical condition which may require treatment?

List any distinguishing markings: Owner’s signature:

To add your pet’s 15 digit microchip number to the International Pet Microchip Database, please send this form along with a $19.95 check or money order payable to: Pet Chip Registry P.O. Box 82952 Tampa, FL 33682