New Customer Registration Form
Customer Details:
Full Name from ID
*
First Name
Last Name
Preferred Name (what will show up on your punch card)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
What type of government assistance do you receive?
*
Please list your pets
*
Pet's Name
Cat or Dog?
Male or Female
Spayed or Neutered
1
2
3
4
5
6
7
8
Please upload a photo of your proof of government assistance (must include your name).
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a photo ID such as a driver's license or Clarity Card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: