NAME/TITLE_________________________________________________________________________________________________

AGENCY_____________________________________________________________________________________________________

AGENCY ADDRESS___________________________________________________________________________________________

______________________________________________________________________________________________________________

SUPERVISOR_________________________________________________________________________________________________

AGENCY PHONE_____________________________________HOME PHONE___________________________________________

HOME ADDRESS______________________________________________________________________________________________

______________________________________________________________________________________________________________

SEMINAR  YOU WILL BE ATTENDING__________________________________________________________________________

K9 NAME____________________________________________________________AGE OF K9______________________________

BREED OF K9________________________________________________________YEARS OF SERVICE_____________________

K9'S  TRAINER________________________________________________________________________________________________

NAME AS IT IS TO APPEAR ON THE ATTENDENCE CERTIFICATE

________________________________________________________and K-9_______________________________________________

EMAIL ADDRESS_____________________________________________________________________________________________

PAYMENT METHOD:

CASH________ MONEY ORDER_________CHECK__________