APPLICATION FORM - REGISTRATION OF INDIVIDUAL DOG

FEE_____________ (6/98) Reg. # given by office ______________________

 (Must be accompanied by legible copy of registration from FCI or other recognized registry (rare breed dog show clubs in US are NOT recognized registries), and a minimum of 3 generation pedigree. Special cases will be reviewed by Officers of this club on a case by case basis. Additionally a front profile photo and a full side body photo shall accompany this request and becomes a part of this registration application.) Print legibly and exactly how names are to appear.

USA BRED ________ COUNTRY OF ORIGIN _________ IMPORTED DATE ________________

REGISTRATION NUMBER & NAME OF RECOGNIZED REGISTRY:

__________________________________________________________

SEX:_________ DATE OF BIRTH ______________ LITTER #(if applicable) __________________

NAME TO BE REGISTERED: ______________________________________________________

(Limit to 30 spaces including commas and spaces between words/names)

REGISTERED NAME & NUMBER OF SIRE:

___________________________________________________

REGISTERED NAME & NUMBER OF DAM:

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COLOR ______________ MARKINGS_____________________________________________
(acceptable colors: fawn/red; light fawn/red; deep fawn/red; (self colored white or with extensive white markings, ie: full white collar are less appreciated.)

BREEDER(S): ___________________________________________________________________

BREEDER ADDRESS: _____________________________________________________________

PHONE NUMBER IF POSSIBLE WITH COUNTRY CODES: ______________________________________

OWNER(S): ____________________________________________________________________

FULL ADDRESS, PHONE NUMBER, AND E-MAIL ADDRESS ON EACH OWNER:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

HEALTH CLEARANCE NUMBERS AND INFORMATION:

______________________________________________________________________________

______________________________________________________________________________

MICRO CHIP # & COMPANY: ________________________ TATOO #: (if applicable) _____________

I submit that this is true and accurate information regarding this animal to the very best of my knowledge.

DATE: _________________ OWNER(S) SIGNATURE(S):_____________________________


PLEASE REPORT DATE & CAUSE OF DEATH TO THE PARENT CLUB!