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This Old Cat, P.O. Box 320, Honeoye, New York 14471-0320 USA
local phone 585-919-6557  toll-free phone 1-866-388-4707  toll-free fax 1-866-343-2737
email thisoldcat@rochester.rr.com      www.TheSunshineHome.com

TEXT LONG-TERM CARE APPLICATION
(type your answer on the line after each item)

***************** PART A *******************************
Complete Part A giving us your information.  Information about
your cat(s) goes in a separate form, Part B.
*********************************************************

Today’s Date:

 
Title (i.e., Miss, Mr., Dr., etc.):

					
1st Person's Full Name:


2nd Person's (if applicable) Full Name:


Current Mailing Address (Number & Street or PO Box, City, State  Zip):


Current Residence (Number & Street, City, State  Zip):


Current Daytime Phone Number:


Current Evening Phone Number:


Current Cell Phone Number:


Current Fax  Number (if any):


Email Address:


Name & Address of  Employer  (if currently employed):


Name of Veterinary Hospital:


Address of Veterinary Hospital  (Number & Street, City, State, Zip):


Phone Number  of Veterinary Hospital:


Emergency Contact(s) – A list of names, phone numbers, etc. of other people to contact while your cats are with us
 (this is needed only if you are considering TEMPORARY Care for your cats).




PLEASE INDICATE THE TYPE OF CARE YOU NEED FOR YOUR CATS (type an X in front of your selection):
  _  TEMPORARY Care (Long-term Boarding)
	Estimated Arrival Date:
	Estimated Departure Date:
  _  PERMANENT Care
	Estimated Arrival Date:
  _  UNDECIDED between Temporary and Permanent Care at this point.


I am considering The Sunshine Home for the following reason:





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Rev4-08022009
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