Designer Breed Registry                                                                                                                Order Breeder Certificate   
                                                




INFORMATION                      

Please print clearly in capitol letters
Name                                                                                                                Breeder Number                            Kennel Name if applicable

______________________________________________           ________________  __________________________________________________
Breed #1                                                                                                                Breed#2                                                    Breed #3

_________________________________________  ______________________________________  _____________________________________  
Address                                                                                                                      City                                                      Country/State    

____________________________________________  ________________________________  ________________________________________
Postal/Zip Code                                              Phone                                                                       Email

___________________________  ___________________________________  ______________________________________________________
 
                                                                                  Payment

Charge my:  (   )Discover       (   )MasterCard       (   )Visa    (   )Amex    (    )PayPal     (   )Check    (   )Money Order  
                                                                           
 Certificate $25.00

Name on Credit Card______________________________________________________________
Account Number                                                                                                                                 Exp. Date                        cvs code
___________________________________________________ ______/ ____ / ______          ______________

__________________________________________________   __________________________________________________
Billing Address if different than mailing address                                        City                                                 State/Country
International Orders please add an additional $5.00 for shipping and handling
Send completed application to:
Designer Breed Registry/ Registered Kennel Name
PO Box 238
Barryton, Michigan  49305
1-732-256-9415