North American Purebred Dog Registry

P.O. Box 417, Olney, IL 62450

Phone: 618-395-3926

Fax: 618-395-3928

Website: www.napdr.com E-mail: napdr@napdr.com

INDIVIDUAL REGISTRATION APPLICATION

REGISTRATION FEE: $10 PER DOG (PAYMENT MUST BE IN U.S. FUNDS)

A PUREBRED DOG THAT DOES NOT HAVE REGISTRATION PAPERS MAY BE REGISTERED WITH NAPDR. IF YOU ARE 100% SURE OF THE DOG'S BREED, FILL OUT THE INFORMATION YOU KNOW AND WRITE UNKNOWN ON THE OTHER PLACES. PAYMENT MAY BE MADE WITH CHECK, CASH, CREDIT CARD or MONEY ORDER.

PLEASE PRINT OR TYPE:

NAME OF DOG:_____________________________________________________

LIMIT NAME TO 25 LETTERS

BREED:___________________________________________________________

BIRTH DATE:__________________________SEX:________________________

COLOR: __________________________________________________________

LIST ANY MARKINGS OR IDENTIFICATION NUMBERS YOU WOULD LIKE ON YOUR PAPERS

_________________________________________________________________

IS DOG REGISTERED WITH ANOTHER REGISTRY? YES____NO____

IF YES, PLEASE GIVE NAME OF REGISTRY_____________________________

SIRE:____________________________________________________________

IF SIRE IS REGISTERED WITH NAPDR, GIVE NAPDR #

_____________________________

DAM:_____________________________________________________________

IF DAM IS REGISTERED WITH NAPDR, GIVE NAPDR #

_____________________________

BREEDER:_________________________________

FIRST M LAST

OWNER: (PLEASE PRINT) CO-OWNER: (PLEASE PRINT)

________________________________ ____________________________

FIRST M LAST FIRST M LAST

________________________________ ____________________________

ADDRESS ADDRESS

________________________________ ____________________________

CITY STATE ZIP CITY STATE ZIP

PHONE:__________________________ PHONE:______________________

E-MAIL ADDRESS_______________________

SIGNATURE OF AT LEAST ONE OWNER:___________________________

Credit Card #_____________________________________________ Expiration Date_______/_______

CSC Number____________________________Total Amount $______________

Name as it appears on card________________________________Home Phone____________________

Billing Address__________________________________/_____________________________________

City State Zip