* KENNEL NAME:

* CONTACT PERSON:

* BREEDER CKC NUMBER

* Business Name & Mailing Address:

* Preferred Retail Store

* Tel.: () Fax: ( )
* Email:
Website

Category membership (check as applicable):
Kennel Breeder  Other (please specify) 

Years in business:  

Memberships – Please list all club (e.g. Canadian Kennel club) memberships, breed clubs, associations etc.
1.
2.

Please list breeds:
1.
2.
3.

Number of dogs enrolled:
Product you will be feeding (please check):  
ACANA   ORIJEN   BOTH

What other product(s) are you feeding?