Camila

Application to register a Litter resulting from Artificial Insemination using Fresh extended semen

*BQ1AB*

bQ1Ab

Use this application to register a litter of puppies, resulting from artificial insemination, that was inseminated and whelped in the USA from an AKC® registered female and the fresh extended semen of an AKC registered male or an approved foreign male of the same breed.Important information and instructions are on page 3 of this form; the mandatory requirements section contains critical information. registration is not guaranteed. processing fees are nonrefundable, and all fees are subject to change without notice. Litter and Payment Information Litter Date of Birth: Calculate this litter’s puppy fee: number living: males Month Females See page 3 of this form forcomplete details Breed: Year Total puppies x $2.00 processing Fee puppy Fee expedited handling Late Fee Total Fee Charge my: VISA AMEX MasterCard Discover $ $ $ $ $ 2 5

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Day

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Enter $35.00 to request expedited handling. See page 3 for details. Enter $65.00 if it has been more than 6 months since the litter was whelped.

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Printed Name of Cardholder

Account Number (do not includedashes)

Expiration Date

Sire (Male) Information: To Be Completed and Signed by an Owner/Co-Owner of the Sire

AKC Number of Sire (Male)

Registered Name of Sire (Male)

The dog has previously been AKC DNA Profiled. AKC DNA Profiling is required for all stud dogs whose semen is collected for fresh extended use. (If the sire is not AKC DNA Profiled, please submit a completed AKC DNA kit withthis application.)
I (we) authorize Authorized Person

to extract and extend semen from the above identified dog.

Owner’s First Name

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Owner’s Last Name Email Address - Provide your email address to receive important AKC communications.

Telephone Number

By signing, I agree to the arbitration clause at the bottom of this page.

Owner’s/Co-Owner’s Signature Dam (Female)Information: To Be Completed and Signed by All Owners or Lessees of Dam on Date of Insemination AKC Number of Dam (Female) Registered Name of Dam (Female)

I (we) certify that I (we) am (are) the owner(s) or lessee(s) of the identified Dam and that on ____/____/________ (mm/dd/yyyy) I (we) authorized the person listed below to artificially inseminate said female with semen extracted and extendedfrom the above identified male. No other male serviced my female prior or subsequent to this artificial breeding during the female’s season. I (we) witnessed this artificial mating:

Authorized Person

Yes

No

1st Owner’s First Name 2nd Owner’s First Name

1st Owner’s Last Name 2nd Owner’s Last Name

By signing, I (we) agree to the arbitration clause at the bottom of this page.

1stOwner’s Signature Notification of Change in Ownership or Lease Check here if the ownership or lease of the Dam changed between the date of insemination and the date the litter was born. Arbitration Clause

2nd Owner’s Signature

I (we) Agree ThAT Any CAuse oF ACTIon, ConTroversy or CLAIm ArIsIng ouT oF or reLATed To ThIs regIsTrATIon or As To The ConsTruCTIon, InTerpreTATIon And eFFeCT oF ThIsAgreemenT shALL be seTTLed by ArbITrATIon pursuAnT To The AppLICAbLe ruLes oF The AmerICAn ArbITrATIon AssoCIATIon. however, prIor To ArbITrATIon ALL AppLICAbLe AKC byLAws, ruLes, reguLATIons And proCedures musT FIrsT be FoLLowed As seT ForTh In The AKC ChArTer And byLAws, ruLes, reguLATIons, pubLIshed poLICIes And guIdeLInes. ALAIFX (1/10) ©2010 The American Kennel Club

AmericAn Kennel club®Sire and Dam Information

Application to register a Litter resulting from Artificial Insemination using Fresh extended semen

*BQ2AB*

Please reenter the registration numbers of the Sire and Dam from page 1

bQ2Ab

AKC Number of Sire (Male) AKC Number of Dam (Female) Dam (Female) Information: To Be Completed and Signed by All Owners or Lessees of Dam on Date of Birth AKC will send the...