Name of Organization: _______________________________________

Street address or P.O. Box: __________________________________

City, State, Zip: _____________________________________________

Contact Person: _____________________________________________

Telephone: _________________________________________________

Best times to call: ___________________________________________

Web Page Address: __________________________________________

Linked to IDA: Yes ______ No ______

Name and location of targeted pet store(s):

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Name and location of preferred pet store(s):

__________________________________________________________

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Please check and indicate how many of the following items we can supply:

( ) Petland flyers _____

( ) Puppy mill brochures _____

( ) General Generic pet store flyer _____

Additional remarks and/or suggestions would be appreciated:

__________________________________________________________

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