Dog’s registered name:______________________________________________

Registration #:_____________________________ Date of birth:_____________

Breed:________________________ Color:__________________ Sex: M or F

Registration # of sire:_______________ Registration # of dam:______________

Owner name:______________________________________________________

Co-owner name:___________________________________________________

Street Address:____________________________________________________

City/State/Zip:_____________________________________________________

Phone:________________________ E-mail:_____________________________

Circle testing requested:

Cardiac Auscultation ($45) Thyroid ($80)

Patella’s ($15, $10 if 4 or more from same owner) AVID Microchip ($30)

Mail 1 form per dog and check for total fees (payable to Brazoria Kennel Club) to: Jennifer Kyle, 205 Washington Ave, Clute, TX 77531