Applications may be copied to your printer or obtained from:

Address: GDC, PO Box 222, Davis, California 95617
Phone/Voice Mail/Fax:-530-756-6773

Updated Nov. 3, 1997

GDC Eye Registry

Application FORM
OPHTHALMOLOGIST'S NAME
BREED SEX
DOG'S REGISTERED NAME
CALL NAME NUMBER IN LITTER
KC REGISTRATION No. BIRTH DATE
OWNER'S NAME
OWNER'S ADDRESS
CITY STATE ZIP PHONE
NAME OF BREEDER
BREEDER'S ADDRESS
CITY STATE ZIP PHONE
SIRE'S REGISTERED NAME SIRE REGISTRATION No.
DAM'S REGISTERED NAME DAM REGISTRATION No.

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.

Signature:______________________________________________________________________________ Date:__/___/__________

Institute for Genetic Disease Control in Animals /2295761@mcimail.com/ Revised October 2, 1997

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