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Fill and Sign the Basic Dog Boarding and Training Client Intake Form

Fill and Sign the Basic Dog Boarding and Training Client Intake Form

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NEW AGENT / LEVEL 4 SETUP DoD – 3058 Reporting Levels Level 1 _ _ _ _ _ Level 2 _ _ _ _ _ Level 3 _ _ _ _ _ Level 4 _ _ _ _ _ Setup Information Cycle Date _ _ Agency/Organization Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (max. 40 char.) Recipient Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (max. 30 char.) Please choose one: Primary Alternate Please choose one: A/OPC Finance Officer Address Line 1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (max. 40 char.) Address Line 2_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (Optional) (max. 40 char.) City _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State _ _ (max. 15 char.) Zip _ _ _ _ _ - _ _ _ _ Country _ _ _ (max. 9 char.) Phone Number_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (max. 20 char.) Fax Number_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (max. 18 char.) Email address__________________________________________________________________ (max. 60 char.) Paper Report Selection Information If you have questions about your reporting package, please contact your Account Coordinator. No Reports Agency/Org. Standard Reporting Package Template Name ____________________________ Other (Complete Report Selection Form) Form Submitted by A/OPC: Signature__________________________________ Phone________________________ Print Name ___________________________________ Fax __________________________ Date Submitted _______________ FAX REQUEST TO 612-973-3791 or 1-800-974-0777 OR MAIL REQUEST TO: U.S. BANK GOVERNMENT SERVICES 200 SOUTH SIXTH STREET – EP-MN-L28C, MINNEAPOLIS, MN 55402 AGTSET- 1/08 Page 1 of 1

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