Registration Form
National Dog Registry •  P.O. Box 51105 •  Mesa, AZ 85208• (800) NDR-DOGSEthics, Dependability, Honor

OWNER INFORMATION PET INFORMATION
Name: * Tattoo Number: *
Address: * Indicate all letters, numbers, and symbols that
physically appear on this pet.
City: *
State: * Zip: * Microchip Implant Number:
Telephone (H): * Company:
Telephone (W): * Pet's Call Name: *
Cell: Pager: Dog  Cat  Other
Email: * Fax: Specific Breed (s):
IMPORTANT: In case of emergency, give name of relative/
friend at an address OTHER THAN YOURS. THIS MUST
BE FILLED IN. Additional names can be listed below.		 Color (s):
Special Markings:
Name: *
Telephone (H): * Emergency Data:
Telephone (W): *
TATTOOER / IMPLANTER INFORMATION Prescription Names & Dosage:
NDR Agent #
(To be completed only by Authorized Agent) Allergies:
Name: Veterinarian Name:
Address: Veterinarian Phone:
City:        
State: Zip:        

1) I, the above named owner, empower NDR to authorize emergency pet care, in my name, should my pet
    become injured and I cannot be reached.  (Check this box if you do not agree to this provision NO )
2) I understand that NDR is not responsible for any lost, late, non-delivered, or misdirected mail.
3) I will use the NDR official Change Of Information Form to keep NDR advised of my current information
    (Available online Here and enclosed in confirmation packet)
4) I also hereby swear that the above is true and correct and that I am the legal owner of the above-named pet.

A lifetime membership for the dog in the National Dog Registry costs only $45. If you would like to add a pet to the same home the fee $20. This fee protects privately owned tattooed or implanted pet you own. Your membership also gives you access to other services NDR provides, including a pet-owner’s kit, unlimited access to our missing pet counseling service, support products, and more.
   Give Your Pet A Way Home
All Material and contents (except where quoted from other sources) Copyright © 2004 National Dog Registry. All rights reserved. Reproduction or other use without the express written permission of National Dog Registry is prohibited.