P.O. Box 177, Warner, NH 03278
Phone: 603-456-2350 Fax: 603-456-2286
EMAIL: gdc@conknet.com
http://www.vetmed.ucdavis.edu/gdc/gdc.htm

FOR GDC USE:
Ck. No.
Dog No.
A:
E:

GDC is a Non-profit, Tax-exempt organization.

Application

EYE EVALUATION and REGISTRATION

This application may be copied to your printer or obtained by mail or fax from GDC:
OPHTHALMOLOGIST'S NAME, Please Print
BREED SEX

DOG'S REGISTERED NAME
CALL NAME

 NUMBER IN LITTER
K.C. Registration No.

 Birth Date
Owner's Name
Owners Address
City

 State

 Zip

 Phone

 FAX or E-Mail:
Name of Breeder
Breeders Address
City

 State

 Zip

 Phone
Sire's Registered Name

 K.C. Regis.

Dam's Registered Name

K.C.Regis.

Fee included (payable to GDC) $ ______

No charge for Affected Entries

I hereby certify that the data submitted is of the dog described on this application. I am aware that the data will be public information and will be maintained for the purpose of improving the breed and lowering the risk of genetic diseases, as well as for research purposes.

Owner's signature:_______________________ Date:___/___/____

Return

Institute for Genetic Disease Control in Animals / Revised 10/02