First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

County

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

Text/Pager Email

Please provide your full name as it appears on your Veterinary Permanent ID.*

Please provide your Veterinary Permanent ID number and expiration date.*

Please provide the address of your Veterinary business.*

Please provide the phone number for your Veterinary business.*

How long have you known this client?*

Please provide the name of your client that has asked you to fill out this form.*

Please list the number and type of other animals that this client has.*

Is there any reason that you would not recommend this client as a candidate to adopt a Siamese cat/kitten?*

By filling out this form, I certify that this information is true and accurate to the best of my knowledge. This letter of verification will be kept on file with MISR. I also agree to answer any additional questions that a MISR representative may have regarding the health and care of all animals that I have taken care of for this client. MISR agrees to hold you harmless and free of any liability regarding any information that you might give to MISR.*