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:
________________________________________
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