Bar Coded Id - ENROLLMENT FORM If paying with check or money order-fill this form out, print it and mail it with a print out of your order confirmation and payment.The cost is %15.00 per bar code and they will be mailed free of charge by USPS Priority Mail./> The insert/tag is 2 inches long and 1/2 inch high and can be cut on the center line or folded in half to make a 1 inch by 1/2 inch insert.It is made of lead free, fire resistant and waterproof, non-toxic material. The 1/2 bar code seen of the right side of the image, above, contains all of the person or pet's information. There are NO Monthly or Yearly fees involved! Our bar coded water proof tags can be read by the 2-d scanners or many modern cell phones. Your tag can be replaced by keeping your order confirmation number. All information is stored securely on Pro stores servers. Please file out ONE form for each for each Id you purchase. EXAMPLE: If you purchase 2 pet ids and one person id- another blank form will appear as soon as one is completed until 3 unique forms have been filled out. What ever you enter below will be converted to bar code by our secure system. Please fill this form out completely. If you have other notes about this person or pet that someone should know if they are found, please enter the information below. Thank you. The needed information will be converted to a tiny bar code and printed on a water proof, heat resistant and lead free tag that can be inserted in or on your dog Id Tag. or a persons medical alert bracelet or any type of jewelry. It comes as a "peel off " sticker that has permanent glue on the back.  Requires Adobe Acrobat Reader to view.

YOUR CONTACT INFORMATION Name: Home Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email:	PERSON / PET'S MEDICAL INFORMATION Doctor/Vet's Name: Their Clinic or Hospital Name: Their Phone Number City: State: Zip: Allergies?: Critical Illnesses: Medications Needed in Emergency if Available:
INFORMATION                                                                                       Is your pet friendly? (for example, Can strangers approach safely) Yes No
BACK UP EMERGENCY CONTACT Name: Address: City: State: Zip: PHONE #	OFFICE USE ONLY Date of purchase: _______________ For a person: _______________ For a Pet: _______________ Customer Confirmation #: _______________
If for any reason, you are mailing, faxing or emailing this form to us to purchase an Id, please make sure you write your order Hillrise Farm Order confirmation# here.____________________. Otherwise our program does it for you and we do not have to reenter by hand.  Typed or Original SIGNATURE: ________________________________________ DATE: ____________________