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CHINESE SHAR-PEI CLUB OF AMERICA, Inc. |
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CSPCA Longevity Program
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| _______________________________________________ |
_____________________________ |
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| Registered Name of Dog (including titles) | AKC/CSPCA/other Registration Number | ||||||||||||
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(A
copy of the registration certificate is required before application can
be proecessed) |
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_______________________________________ |
________________________________________ |
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Registered name of Sire |
Registered name of Dam |
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| Coat Type (circle one): Horsecoat Brushcoat Bearcoat |
Gender (circle one): Dog Bitch |
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| Date of Birth: ______________________________ |
Date of Death: ________________________________ |
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Cause of Death: ____________________________________________________________________________ |
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(Optional, but if included must be verified with copy of necropsy report) |
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| Breeder(s) Name | ______________________________________________________________ | ||||||||||||
| Owner(s) Name | ______________________________________________________________ | ||||||||||||
| Address | ______________________________________________________________ | ||||||||||||
| City | ______________________________ | State/Providence __________ | Zip |
___________ | |||||||||
| Phone | _______________________ |
Day time or Evening |
E-mail _______________________________________ | ||||||||||
