Designer Breed Registry Order Breeder Certificate
INFORMATION
Please print clearly in capitol letters
Name Breeder Number Kennel Name if applicable
______________________________________________ ________________ __________________________________________________
Breed #1 Breed#2 Breed #3
_________________________________________ ______________________________________ _____________________________________
Address City Country/State
____________________________________________ ________________________________ ________________________________________
Postal/Zip Code Phone Email
___________________________ ___________________________________ ______________________________________________________
Payment
Charge my: ( )Discover ( )MasterCard ( )Visa ( )Amex ( )PayPal ( )Check ( )Money Order
Certificate $60.00
Name on Credit Card______________________________________________________________
Account Number Exp. Date cvs code
___________________________________________________ ______/ ____ / ______ ______________
__________________________________________________ __________________________________________________
Billing Address if different than mailing address City State/Country
International Orders please add an additional $`15.00 for shipping and handling
Send completed application to:
Designer Breed Registry/ Registered Kennel Name
PO Box 238
Barryton, Michigan 49305
1-732-256-9415
INFORMATION
Please print clearly in capitol letters
Name Breeder Number Kennel Name if applicable
______________________________________________ ________________ __________________________________________________
Breed #1 Breed#2 Breed #3
_________________________________________ ______________________________________ _____________________________________
Address City Country/State
____________________________________________ ________________________________ ________________________________________
Postal/Zip Code Phone Email
___________________________ ___________________________________ ______________________________________________________
Payment
Charge my: ( )Discover ( )MasterCard ( )Visa ( )Amex ( )PayPal ( )Check ( )Money Order
Certificate $60.00
Name on Credit Card______________________________________________________________
Account Number Exp. Date cvs code
___________________________________________________ ______/ ____ / ______ ______________
__________________________________________________ __________________________________________________
Billing Address if different than mailing address City State/Country
International Orders please add an additional $`15.00 for shipping and handling
Send completed application to:
Designer Breed Registry/ Registered Kennel Name
PO Box 238
Barryton, Michigan 49305
1-732-256-9415
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