Date:

Owner Name  (F,M,L):  ___________________   _____    ____________________



Company: ______________________________________________________________



Address ________________________________________________________________



City___________________________________________  State  ______   ZIP _____



Nite Phone: 

Day Phone:

Fax Phone:

Email Address:

Intrnl Airport:



Dog Name Field:		Reg Name:			AKC #:

DOB:			Weight:				UKC #:

NAVHDA Rank:						DOT:

Pointing Certification

	IPLA #:						DOT:

	APLA #						DOT:

Height at Shoulder:

Body Type:		

	Brit

	Amerc

Coat Color:

Coat Thickness:

Head Conformation:

Parents Names & AKC #’s	

	Sire:

	Dam:

AKC Official Pedigree Available? Yes     No     When?

Sperm Count:			DOT:		Copy?		Vet N&N:		

OFA #:						Copy?		Rad N&N:

	Xray History:

PennHIP#:			DOT:		Copy?		Rad N&N:

CERF#:					        Copy?		Opth N&N:

Bloods

	Brucellosis: (MANDATORY BEFORE BREEDING)

	Thyroid: (MANDATORY BEFORE BREEDING)

Field/Trial/Bench Titles:

Unusual Traits:

Stud Fee:

GENERAL COMMENTS: