Your Full Name:*

Full Address:*

Email(s): *

Phone(s):*

Registered owner of dog (co): *

Registered Name of Dog: *

Date of Birth of Dog:*

Gender:

Call Name:

Color (white/white-factored/colored):

Registered Name of Sire:

Sire's Call Name:

Registered Name of Dam:

Dam's Call Name:

Hips certified by (OFA, PennHIP, OVC, Other):

Hip Eval Date:

Age of Dog When Eval:

Elbows certified by (OFA, PennHIP, OVC, Other):

Elbow Eval Date:

Age of Dog When Eval:

List any other health clearances:

Clearance Date:

Age of Dog When Cert:

Please add important comments.