Application for Individual Registration

Name of Dog or Bitch________________________________________AMDCA No.___________Sex___

(Use individual AMDCA number assigned by breeder at litter registration )

Name and address of new owner: ___________________________________________________________

Street_______________________________________________Tel.( )_____-_____

City__________________________________State_______________Zip____________

Other tel: ( )_____-_________ e-mail: _________________________

Name and address of co-owner (if any):_____________________________________________________

Street_______________________________________________Tel.( )_____-_____

City__________________________________State_______________Zip____________

Other tel: ( )_____-_________ e-mail: _________________________

For Completion By Breeder:

Name and No. of Sire: ____________________________________AMDCA No__________Sex_____

Owner of Sire:_________________________________________ Tel.( )_____-_____

City__________________________________State_______________Zip____________

Country: ________________

Other tel: ( )_____-_________ e-mail: _________________________

Name and No. of Dam: ___________________________________AMDCA No__________Sex_____

Owner of Dam:_____________________________ ___________ Tel.( )_____-_____

City__________________________________State_______________Zip____________

Country: ________________

Other tel: ( )_____-_________ e-mail: _________________________

I, as the Breeder of this litter, certify that on (date): __________________, this Appenzell Mountain Dog was sold in good health and temperament as a (circle one): SHOW/BREED PET

Quality specimen. I understand that it is my responsibility to provide the new owner with a four-generation pedigree. This dog or bitch is from AMDCA Litter No. _____________, which was whelped on

_________________________.

Signed, ____________________ Breeder

I certify that this litter was registered with the AMDCA on _____________________________.

Signed, ______________________ Registrar

(Audrey Lyke, Registrar)

INSTRUCTIONS TO APPLICANT:

Submit two photographs of your dog (one a standing front view, and the other a standing side view) along with this completed application form to the Club's Registrar. (Malena Brisbois, AMDCA, 7469 Greenwich Rd, Nokesville VA 20181). Include a check for $15 payable to AMDCA. You should receive your certificate in four to six weeks. Do not change the name of the dog or alter this form in any way (other than to make spelling corrections).