DOG ADOPTION/CLOSE-OUT FORM

Note: This form can only be filled in by an IMPS Volunteer. If you are not an IMPS Volunteer and you have picked up a dog, please call the IMPS Hotline at 1-877-Minpin1, or contact an IMPS Regional Coordinator nearest to you.

DOG INFORMATION

Name of Dog:
IMPS Tag Number:
Microchip Brand &
Number (affix sticker):
Age: Sex:   Color:
 

ADOPTER'S INFORMATION

Name:
Address:
Phone Numbers:
Total Adoption
Amount Paid $
Is this adoption on a payment plan?
Amount sent with this form:
Amount and frequency of payments:  
 

VOLUNTEER INFORMATION

IMPS Volunteer's name:
Email address:
Regional Coordinators name:
Date:
 
 
VOLUNTEERS, PLEASE PRINT AND MAIL THIS FORM WITH THE CHECK IMMEDIATELY FOLLOWING THE ADOPTION TO YOUR REGIONAL COORDINATOR OR OTHER DESIGNATED PERSON.

ALTERNATIVELY MAIL TO:

IMPS, Inc.
P.O. Box 176
Pinellas Park, FL 33780