Duplicate Certificate Registration Application

AP1ADRequest for a DuplicateRegistration CertificateUse this form to request a duplicate Registration Certificate for a dog. Detailed instructions andsubmission requirements are at the bottom of this form. Please use black ink and capital letters to fillin the boxes. Information you omit or print outside of the boxes will delay processing. Processingfees are nonrefundable, and all fees are subject to change without notice.FeesSee the bottom of this form for submittal informationSend the completed application to the address specified on the bottom of this form.Processing Fee $ 2 0Charge my: VISA AMEX MasterCardAccount Number (do not include dashes)Dog InformationDiscover_Check or money order payable to: The American Kennel ClubExpiration DatePrinted Name of CardholderAKC ® Registration NumberSex:Breed:Male FemaleOwner InformationAKC Registered NameFirst Name Last Name Owner’s SignatureMailing Address_City State ZIP code + 4_Telephone Number_Email AddressIf the dog’s AKC registration number is unavailable, please provide the following information:Dog’s dateof birth:Month_Day_YearDam’s AKC Registration NumberDam’s AKC Registered NameSire’s AKC Registration NumberSire’s AKC Registered NameRequirements, Instructions, and General InformationRequirementsThis request must be completed and signed by the owner of the dog as shown on AKC records.MailingInformationAuthorizationsSend this form and all appropriate fees to:The American Kennel Club8051 Arco Corporate Drive, Suite 100Raleigh, NC 27617-3390Signatures of persons other than the owners will be accepted only if a properly completed authorization form hasbeen filed with the AKC.Note: These forms are available on our Web site: www.akc.orgAssistance Email AKC at info@akc.org or call 919-233-9767 to speak to an AKC Customer Service Representative, Monday —Friday, 8:30 AM — 5:00 PM. Information about the registration process and downloadable forms are available onour Web site: www.akc.org.NoticeADCERT (09/13)The American Kennel Club reserves the right to correct or cancel for cause the registration of this dog and itsdescendants. Any misrepresentation on this application is one example of for cause cancellation and may result inloss of AKC privileges. By supplying your email address, you consent to receive communications from the AKC andapproved third parties. Processing fees are nonrefundable, and all fees are subject to change without notice.Once submitted, this application becomes the property of the American Kennel Club.© 2010 The American Kennel Club

AP2ADAmerican Kennel Club ®Request for a DuplicateRegistration CertificateInformation that you provide on this side of the form, in any format, will not be processed.Please refer to the Requirements, Instructions, and General Information section onpage 1 of the form for guidance if you need to provide additional information.Come. Sit. Stay. Shop.www.akc.org