On-Line Form for FAXING or MAILING purposes.

FILL IN ON-LINE, PRINT and either FAX or MAIL it.

All information will be held in the strictest of confidence by Home Checkers.

Your Particulars:

Name:
Address:
City:
Province :
Postal Code:
Tel. No.	Area Code: Number:
Tel. No.	Area Code : Number :
Email : :

Appointment Time

Appointment Time ( Preference ) : AM PM Check the boxes on the PRINT copy

Preferred Time: (ie. 9:00 to 12:00 )

Day of Week ( Preferences - Choose one or more) :

Monday Tuesday Wednesday Thursday Friday

Saturday Sunday Check the boxes on the PRINT copy

Specific Date(s) - List one or more

Pet Care Services Information :

Do you have any pets ? Yes ___ No ___

If yes, how many and what type of pets ?

Comments:

PRINT AND FAX TO US AT: (613) 723-6250 OR,

MAILTO:

HOMECHECKERS, 1568 Merivale Road, Suite 321, Ottawa, Ontario, K2G 5Y7.