PLEASE PRINT CLEARLY

Futurity year___________________________________________________________________
AKC Registered Name________________________________AKC Reg. No._______________
Whelping Date ________________________Sex __________ Color ______________________
Sire ________________________________ Dam_____________________________________
Date of Breeding______________________  Estimated Whelping Date _____________________
Name of Breeder ___________________________ Phone (_____) _______________________
Owner of Sire _________________________________________________________________
Name of Person(s) under whom Puppy will be entered in Catalog___________________________
____________________________________________________________________________
Address _____________________________________________________________________
Signature of Owner or Agent __________________________   Check Attached: $____________

Make checks payable to BTCA

Fee of $10.00 will complete eligilibity of each puppy's nomination for the Futurity                Chk#______   Amt ______
Mail all three forms with fee to Futurity Secretary, Alison Ibbitson                                           Postmarked____________
121 Pennapacker, Trappe, PA  19426                                                                                          Processed_____________
                                                                                                                                                      Accepted ___Rejected___
COMPLETE THREE FORMS
(One will be held by Futurity Secretary, one will be returned to you
marked "Accepted" and one will be sent to the BTCA Treasurer.)

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