For Office Use Only s7

THE TASMANIAN CANINE ASSOCIATION INC

APPLICATION FOR OBEDIENCE TITLE

OBEDIENCE: CCD - CD - CDX - UD - UDX – OC RALLY OBEDIENCE: RN- RA- RE- RAE

AGILITY: AD – ADO- ADX- ADM - AG.CH JUMPING: JD – JDO- JDX - JDM

AGILITY GAMES: SD- SDX- SDM- GD- GDX- GDM –SPD-SPM-SPE

TRACKING: TD- TDX- TC TRACK & SEARCH: TSD - TSDX ENDURANCE

FLYBALL: FD – FDEXC – FD CH (Qualifications gained prior to 01/07/2012)

DANCES WITH DOGS: DWDF.S- DWDF.N – DWDF.I- DWDF.A- DWDF.CH DWD HTM.S – DWD.HTM.N –DWD.HTM.I- DWD.HTM.A – DWD.HTM.CH

( PLEASE CIRCLE THE TITLE BEING APPLIED FOR)

I/we hereby make application for the Australian National Kennel Council title indicated above for the dog, the particulars of which are as follows:

NAME OF DOG: ______REG.NO: ______

BREED: ______SEX: ______

BREEDER: ______OWNER: ______

OWNER'S ADDRESS: ______CERTIFICATES WON

CLUB/SOCIETY DATE JUDGE PTS. / PLACING

I/we certify the foregoing particulars to be true and correct.

______Signature/s Date

FEES: TITLES $27.00 (Fee Inclusive of GST)

PLEASE FORWARD TO: TASMANIAN CANINE ASSOCIATION INC, PO BOX 116, GLENORCHY Tas. 7010 Phone: (03) 62 72 9443 CERTIFICATE OF REGISTRATION AND PEDIGREE MUST BE ENCLOSED WITH THIS APPLICATION.

PAYMENT BY CREDIT CARD

Please debit my Mastercard Visa For the amount of $______

Card expiry date _____/______CVC Number______(Last 3 digits on reverse of card)

Card Holder Name: ______

Signature: ______