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| Designer Breed Registry Application To Register A Litter Breed: _____________________________________________________________Date of Breeding:____________/___________/___________ Born:____________/_____________/_____________ Number of Males to Register [ ] Number of Females to Register [ ] If Applicable Sire:_____________________________________________Breed:_______________________________________Reg.#_____________________ If Applicable Dam:____________________________________________Breed:_______________________________________Reg.#_____________________ Owner of Dam Information Name:__________________________________________________________________ Breeder # (if known)_____________________________ Address:_____________________________________________________________________City:____________________________________ Country/State:________________________________Postal/Zip Code:___________________ Phone:_________________________ Please use country/area code Signature of Owner of Dam___________________________________________________Date:__________________________ Owner of Sire Information Name:_________________________________________________________________Breeder# (if known)_______________________________ Address:____________________________________________________________________City:______________________________________ Country/State:_______________________________Postal/Zip Code:___________________ Phone:__________________________ Please use country/area code Signature__________________________________________________________________Date:__________________________ The Designer Breed Registry is not responsible for any misrepresentations or errors in this application. Misrepresentations on this application will result in loss of priviledges for the owner of the dam and/or the owner of the sire. This application will remain the property of the Designer Breed Registry. Method Of Payment ( ) Visa ( ) Master Card ( )Check ( ) Money Order Total $__25.00___ Print name as it appears on credit card:_______________________________________________________________________________________ Credit card #______________________________________________________Expiration Date_________/___________/______________ By signing below cardholder authorizes this charge Signature of cardholder:______________________________________________________Date___________/____________/______________ Please make checks or Money Orders Payable to: Designer Breed Registry Mail to: Designer Breed Registry 20785 30th Avenue Barryton, Michigan 49305 |
| Spayed Neutered Unknown Origin |
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