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| IGCC Breeders� Resource Website Release Form |
| Italian Greyhound Club of Canada |
| Club Canadien du Petit Levrier Italien |
| Application to enter test results onto the IGCC Breeders� Resource Website DOG INFORMATION _________________________________ __________________ Dog's Registered Name Registration Number __________ _____________________ ___________________ Sex Color Date of Birth _________________________________ Permanent ID (DNA/Microchip/Tattoo) OWNER�S INFORMATION __________________________________ ___________________ Owner(s) Telephone Number __________________________________ ___________________ Mailing Address Email Address __________________________________ Province & Postal Code DIAGNOSIS: ( PRA, Cataract , Vitreous Degeneration Autoimmune Thyroiditis, Patella Luxation, Single Fracture, Multiple Fractures, Tooth Loss <7yrs of age, Tooth Loss > 7yrs of age, Other conditions- please specify) List as many as apply & brief details as necessary _____________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ NOTE: A COPY OF THE OFFICIAL TEST RESULTS CONFIRMING ALL DIAGNOSES LISTED AND A PEDIGREE MUST ACCOMPANY THIS APPLICATION *except for fractures & tooth loss, where you can just note the attending veterinary surgeon & address. I hereby certify that the information provided above is accurate. I hereby authorize release of this information into the public domain of the IGCC Breeders� Resource Website. I understand and acknowledge that anyone with Internet access can view these results. _____________________________ __________________________ Signature of Registered Owner Date |