First Name
Last Name
Home Phone
Work Phone
Fax
Email
Mailing Address
City State Zip

AKC Titles, Name, and Number of your bitch:

Health certifications
PennHIP Rating:
Hip OFA number & rating:
Elbow OFA number & rating:
Last CERF eye check, date & results:
Last Heart check (SAS), date & results:
Last Blood check (vWD), date & results:
Last Thyroid check, date & results:
Last Epilepsy check, date & results:

Approximate date of desired breeding:

Please describe your bitch (size, weight, color. etc.):

Please send the bitchs pedigree ASAP.