Name of owner  : ___________________________________________________________      
        
Address                : ___________________________________________________________
          
                                    _________________________________________________________ __
       
                                    ___________________________________________________________
       
                                   ____________________________________________________________
       
Telephone         :  ___________________________________________________________
       
Email                     : ____________________________________________________________
       
Name of stud dog  : ________________________________________________________
        
Sire of Stud Dog    : ________________________________________________________    
        
Dam of Stud Dog   : ________________________________________________________     
        
Hip Score                  : ________________________________________________________
       
Elbows                        : ________________________________________________________
       
Date of Eye Certificate  : __________________________________________________      
        
              (Please tick following boxes if applicable)        
I confirm that the above details are correct        
        
I agree to donate £15 to BD&CGRC funds      Make cheques payable to   
      Berkshire Downs & Chilterns GRC  
I require a receipt for this donation        
        
        
Signed   __________________________________________________    Date   ______________________
       
Please return this form to Stud Dog List co-ordinator.        
        
Stud Dog List co-ordinator Mrs.Judy Gregory, North Lodge, Tram Hill, Brill, Alesbury,         
Bucks., HP19 9TX   Tel:01844 237644,  Email: puppylinestuddogsbdcgrc@hotmail.com