Breed:

Date Of Birth:

Number of Males:

Number of Females:

Total Amount For Registration (Please Add $5.00 Plus Total # of Puppies):

Sire's ACHClub Name:

Sire's ACHClub Number:

Dam's ACHClub Name:

Dam's ACHClub Number:

Your Name:

Your Street Address:

Your City:

Your State:

Your Zip Code:

Your Phone Number:

Your Fax Number:

Your E-Mail Address:

ACHClub Breeder ID #:

Would You like to add a pedigree? ($5.00 Plus $1.00 per Puppy - Enter Yes or No):

Total Amount For Pedigree(Please Add $5.00 Plus $1.00 per Puppy):

Do You Agree to all of the ACHClub's Terms and Conditions?(Enter Yes or No):

Total Amount For This Registration (Please Add Total Litter Registration Plus Pedigree Total):

Are You Selling direct To The Consumer? If Yes we will include a consumer pamphlet for each puppy (Enter Yes or No):

Your Credit Card Number:

Expiration Date :

Type of Credit Card - Mastercard and Visa ONLY :

Additional Comments:

Do You Also Own The Sire? (Enter Yes or No) - If Yes, skip the Sire Info and submit the registration:

Sire Owner's Name As Listed With ACHClub

Sire Owner's ACHClub Breeder ID #

Sire Owner's Phone Number

Sire Owner's Street Address

Sire Owner's City

Sire Owner's State

Sire Owner's Zipcode

Sire Owner's E-Mail Address