RoHM Individual Dog Application  (Owner must have a RoHM listed kennel) Kennel Name: __________________________________      Breed:____________________________ Owner's Name:   __________________________________________________________ Registered Name of Dog: __________________________________________________ Reg. Nos. of Dog (optional) _______________________ Registry:__________________ Birth Date:      /      /            Height: _______ Color: _______ Coat: ________ SEX:_________ Sire: _________________________________________ Sire's Reg. # ___________________ Dam: _________________________________________ Dam's Reg. # __________________ Pedigree: Five (5) generation pedigree preferred, but at least four (4) generations must be attached and accompany the application. Three (3) generation pedigrees will be published on-line. Photos: Will be published on-line. Health Clearances: Check all that apply and attach hard copies of each test for verification. All test copies must accompany the application. Dogs which are cerfed with Breeder Option Diagnosis must either have a CERF CERTIFICATION NUMBER or have a letter from the attending Ophthalmologist stating the Breeder Option Diagnosis before listing. No Exceptions. BAER: _______ CERF: _______ Orthopedic: _______ Other: _______ If other is checked please list the clearance and attach copies of the tests. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Awards of Merit: Check all that apply and attach copies of awards to the application. Copies of awards must accompany the application ConformationChampionship(s):     List Issuing Organizations: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Natural Hunting Awards: Natural Hunting Certificates: list quarry, date issued, person who witnessed terrier work and organization that issued the working certificate. Must attach a photocopy with application _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Performance Awards: Good Citizen: _______ Obedience: _______ Agility: _______ Earth Dog: ________ G-T-G: _______ Trailing and Locating: _______ Other: _______ Copies of all Health Clearances, Pedigrees, Registration Certificates, Conformation, Hunting and Performance Awards along with completed applications and the required fees must be sent to the RoHM Committee for verification and approval. All decisions of the RoHM committee are final. I certify that the information listed in this application and all information sent to RoHM is correct to the best of my knowledge: Signature: ___________________________________________________________________ Allow 4-6 weeks for completion of the paper work. Fee ($5 US) must accompany the application. Make checks payable to the RoHM Register and mail to: RoHM Register c/o 371 S. Yarnallton Pike Lexington, KY 40510