Untitled Document

Enrollment Type
 
New Membership:
_________    
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:
________________________________    

The list of providers can be seen by clicking this link

 

 
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:
___/___/______
       
Coverage is effective immediately once payment is made.  Please allow 3-4 weeks for receipt of membership card.  Print application and PayPal confirmation to use as proof until membership card is received.
 
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 proccessed 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

"American Pet Care Plan is NOT an insurance plan, but merely a membership plan that allows for discounts on veterinary care. Discounts and any savings associated with the plan MUST be given by a participating provider at the time of service. There will be no reimbursements from American Pet Care Plan for services provided by any veterinarian or pharmacy."