Event Microchip Registration Form
Thank you for being a responsible pet owner! Please complete the registration form below.
Contact Information:
This information will be used to register your pet's microchip. Please ensure all your information is accurate. If your pet is ever lost from home, this information is how they can get back home to you!
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Email
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
ALTERNATE CONTACT
Alternate Contact Name
*
First Name
Last Name
Alternate Contact Relation to You
*
Spouse/Significant Other
Relative (Parent, Sibling, Cousin, etc)
Friend
Neighbor
Other
Alternate Contact Address
Street Address
Street Address Line 2
City
State
Zip Code
Alternate Contact Email
example@example.com
Alternate Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
ALTERNATE CONTACT
Alternate Contact Name
First Name
Last Name
Alternate Contact Relation to You
Spouse/Significant Other
Relative (Parent, Sibling, Cousin, etc)
Friend
Neighbor
Other
Alternate Contact Address
Street Address
Street Address Line 2
City
State
Zip Code
Alternate Contact Email
example@example.com
Alternate Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
VETERINARY CONTACT NAME
Veterinarian Contact
Veterinarian or Vet Clinic Name
Veterinarian Phone Number
Veterinarian or Vet Clinic Phone Number
Format: (000) 000-0000.
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Pet Information
Pet's Name
*
Species
*
Dog
Cat
Other
Breed(s)
*
Color(s)
*
Estimated Age
*
Birthday (if known)
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2006
2005
2004
2003
2002
2001
2000
1999
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1996
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Size
*
Small (under 25 lbs)
Medium (26 lbs - 50 lbs)
Large (51lbs - 100 lbs)
Sex
*
Male
Female
Is your pet spayed/neutered?
*
Yes
No
Unknown
Microchip Number
Barcode
Any special notes or information regarding this pet?
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I certify that: I am 18 years of age or older; I am the owner of the pet listed above; and I have verified the information provided on the registration form is accurate
*
Yes
I understand that the information provided on this form will be used to register my pet's microchip, and I consent to the release of my information for reunification purposes to private citizens or animal welfare organizations who might find my pet.
*
Yes
I consent to Aggieland Humane Society using photographs taken of me/my pet for promotional purposes on their website and social media pages.
*
Yes
Submission Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: