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New Pet Form

Date

Owner Name(Required)

Address(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Phone(Required)

Email(Required)

Pet's Name(Required)

Species(Required)

Breed(Required)

Gender(Required)

Male

Female

Spay/Neuter?(Required)

Color(Required)

DOB(Required)

Age(Required)

Secondary Phone Number(Required)

Email(Required)

Capitol Illini would like permission to use your pet(s) photograph on our Website, Newsletter, Facebook, and/or other. Your pet’s information may be used but we will not give any personal information of the owner such as name/address. I give permission for Capitol Illini to use my pet(s) photograph as often as they would like.

PAYMENT IS EXPECTED IN FULLAT THE TIME OF SERVICE

A finance charge of 1.5% applied to all accounts unpaid after 30 days. A billing charge of $2.00 is added monthly. A 35% of the unpaid balance will be applied to any account that is being referred to a collection agency.

Owner: Driver's License #

OWNER SIGNATURE(Required)

CO-OWNER SIGNATURE(Required)

Only the above signatures will have access to or the authorization to change or transfer any information on this account.

Federal Trade Commission-Red Flag Rule-Theft Identity Photo ID has been verified by(Required)

New Pet Form

PAYMENT IS EXPECTED IN FULLAT THE TIME OF SERVICE

Get in touch

(217) 483-6830

(217) 546‑1541

Business Hours

(217) 483-6830

(217) 546‑1541