Belgian Sheepdog Club of America, Inc.

HEALTH REGISTRY LITTER REGISTRATION FORM

Use this form to notify the registry of any litters produced by your dog during the previous year.  Use a separate form for each litter produced. Please supply names/addresses of puppies' new owners and registration number of puppies. Copies of the health registry questionnaire will be mailed to the individuals below when the puppies are approximately two years old.

IDENTIFICATION OF DAM

Registered Name:_________________________________________________ Registration # (AKC or UKC):___________

IDENTIFICATION OF SIRE

Registered Name:_________________________________________________ Registration # (AKC or UKC):___________

Circle one: Natural breeding  Artificial insemination: Fresh semen Chilled semen Frozen semen

Whelping date: ____________  # of males: _________  # of females __________  # of Puppies alive at 8 weeks _________

Please supply information on any significant health problems with the litter:_______________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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IDENTIFICATION OF BREEDER

Your Name:_________________________________________________________________________________________
Address:___________________________________________________________________________________________
Phone :______________________________________________

RELEASE

I am the breeder of the litter identified above.  I have personal knowledge of the information provided and it is true and correct as of this date.  I understand that the Belgian Sheepdog Club of America intends to provide this information on request to club members who participate in the health registry and hereby permit the Club to do so.  I waive any and all rights I may have against the Club in connection with its use of this information.

Signature:___________________________________________________________________________________Date:_______________________

Please provide the following information for each puppy, if known (continue on additional pages as needed):

1.  Registered Name:____________________________________________ Registration # (AKC or UKC):_____________
Owners name/address:_________________________________________________________________________________
___________________________________________________________________________________________________

2.  Registered Name:____________________________________________ Registration # (AKC or UKC):_____________
Owners name/address:_________________________________________________________________________________
___________________________________________________________________________________________________

3.  Registered Name:____________________________________________ Registration # (AKC or UKC):_____________
Owners name/address:_________________________________________________________________________________
___________________________________________________________________________________________________

4.  Registered Name:____________________________________________ Registration # (AKC or UKC):_____________
Owners name/address:_________________________________________________________________________________

Mail to: Renee Artymyshyn, M.D., 114 Stanton Road, Flemington, NJ 08822