(attach Pedigree and Litter list) Litter ID code:_________________

Breeder:___________________________ Litter Birthdate_________________

Information contact:(name)______________________________________

(Address)____________________________________

(City, State, Zip)_______________________________

(Phone-day)___________________________________

(Phone-evening)________________________________

(Fax)_________________________________________

(E-mail)_______________________________________

Number of pups: -at birth - live M______ F______ dead M_____ F______

-surviving at 6 weeks - M_____ F_____

-surviving at 6 months - M_____ F_____

-surviving at submission time - M_____ F_____

Known health problems in littler:

(List problem, dog name and ID # form litter list and age of onset and pertinent details)

Other litter notes or comments:

Submitted by:(name)_______________________________ Date:__________________________