titles report order form - american kennel...

AKC®

Breeder of Merit Titles Report Order Form

Prior Names & AddressesList all prior names you have owned/registered dogs under

List all prior states where you lived when registering dogs

Please complete all information to ensure your report is complete.

Customer # (Internal Use Only):

APPLICANT INFORMATION (REQUIRED*)

Date submitted*Current First Name* Middle Initial* Last Name*

Mailing Address, enter both PO Box and Street Address*

CountryCity* State/Province* Postal Code*

Email Address* My AKC Online Account User Name

Make fees payable to

AKC Special Services Department PO Box 900059

Raleigh, NC 27675-9059

FAX 919-816-3770Email breederofmerit@akc.org

For your safety, Do NOT email this PDF form with credit card information and Do NOT include it in the text of an email. Print and mail, FAX or Scan, then email the scan.

Account Number (Do not include dashes) Expiration Date

M M Y Y

Printed Name of Cardholder

Payment MethodVISA AMEXMasterCard Discover Check or Money Order

FEE INFORMATION

Billing AddressName on Card or Check Signee

Address

City

State & Zip Code

Phone # (required)

$75.00Report Cost

© 2017 The American Kennel Club ODMRT2 (9/17) v1.0Edit

AKC Special Services DepartmentPO Box 900059 • Raleigh, NC 27675-9059Fax: 919-816-3770 • breederofmerit@akc.org