Designer Breed Registry®                                                                                                   Litter  Application      

                                      
                                                                            





Breed: ___________________________________________________Born:________/_________/____________

Males[      ]  Females[      ]
                                                                                                                                                                                         
Name of Sire:_________________________________________________

Breed__________________________________________Reg.#________________________(If known)
                                                                                                                                                                                           
Name of Dam:___________________________________________________

Breed:__________________________________________Reg.#_______________________(_if known)
Owner of Litter

Name:________________________________________________DBR Breeder # (if known)___________________  

Address:______________________________________________City:_____________________________________

Country/State:_________________________________________Postal/Zip Code:____________________________

Phone_______________________________  Email:___________________________________________________

Signature of Owner of Dam__________________________________________Date:__________________________

The Designer Breed Registry is not responsible for any misrepresentations or errors in this application.    
Method Of Payment
(   ) Visa     (   ) Master Card     (   )Discover   (   ) Amex   (   ) PayPal   (   )Check     (   ) Money Order           Total $25.00
Print name as it appears on credit card:

_______________________________________________________________________________
Credit Card #                                                                                                      Exp.Date                   cvc code

________________________________________________  ______/______/_____  _____________

By signing below cardholder authorizes this charge

_________________________________________________________Date___________/____________/______________

Please make checks or Money Orders Payable to: Designer Breed Registry
Mail to: Designer Breed Registry
PO Box 474
Farmingdale, New Jersey  07727    Phone: 1-732-256-9415
Spayed Neutered  Unknown Origin
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