| BIRTHDATE | LITTER REG # |
| KEN'L NAME | SIRE NAME |
| BREEDER | DAM NAME |
| BIRTH - (CHECK ONE) »»» | NATURAL BIRTH _____ | C-SECTION _____ | INSEMINATION - (CHECK ONE)»»» | NATURAL _____ | ARTIFICIAL - FRESH (UNCHILLED) SEMEN_____ | ARTICIFIAL FRESH (CHILLED) SEMEN_____ | ARTIFICIAL FROZEN SEMEN _____ |
| SEX (CIRCLE) | PUPPY NAME AND REG.# (INCLUDE STILLBORN AND DEAD IF AVAILABLE) |
BUYER NAME/ADDRESS/PHONE PLEASE PRINT |
| 1. M F N | 1. | 1. |
| 2. M F N | 2. | 2. |
| 3. M F N | 3. | 3. |
| 4. M F N | 4. | 4. |
| 5. M F N | 5. | 5. |
| 6. M F N | 6. | 6. |
| 7. M F N | 7. | 7. |
| 8. M F N | 8. | 8. |
| 9. M F N | 9. | 9. |
| 10.M F N | 10. | 10. |
| 11.M F N | 11. | 11. |
| 12.M F N | 12. | 12. |
| 13.M F N | 13. | 13. |
| 14.M F N | 14. | 14. |
I voluntarily submit the above data for entry into the Berner-Garde database. I authorize release in accordance with Berner-Garde policies, including affected phenotypes at the time I owned the dog(s). I understand that phenotypes that were diagnosed after I relocated the dog are treated as "hearsay" information until verified with the current owner. Signature:________________________________________ Date:__________________ SEND COMPLETED FORM TO: File Manager: Margrit Kitchen, 9401 E. Jadecrest Dr., Sun Lakes AZ, 85248 (email - mkitchen@aol.com) -- Phone (602) 895-2246 Fac (602) 895-2470 or to your site operator listed in the Berner-Garde Guidebook