Page 1 of 2 – STUD SERVICE CERTIFICATE © Copyright CKCSC-USA Revised 8/10//2019 STUD SERVICE CERTIFICATE REGISTERED NAME OF STUD: DATE OF BIRTH: CKCSC (OR OTHER APPROVED) REGISTRATION #: TRANSFER # (if applicable): COLOR: T- CHOOSE ONE OR MORE & GIVE #(s): MICROCHIP: TATTOO: DNA PROFILE: NAME OF OWNER: NAME OF CO-OWNER: STREET: STREET: CITY: STATE: ZIP: CITY: STATE: ZIP: PRIMARY PHONE: PRIMARY PHONE: E-MAIL ADDRESS: E-MAIL ADDRESS: REGISTERED NAME OF BITCH: DATE OF BIRTH: CKCSC (OR OTHER APPROVED) REGISTRATION #: TRANSFER # (if applicable): COLOR: T- CHOOSE ONE OR MORE & GIVE #(s): MICROCHIP: TATTOO: DNA PROFILE: If the stud dog owner is responsible for this mating, complete below: DATE 1: DATE 2: DATE 3: EXPECTED WHELPING DATE: TYPE OF MATING: NATURAL AI AI using FRESH CHILLED SEMEN AI using FROZEN SEMEN IS THIS BREEDING FOR A STUD FEE PUPPY? YES NO NUMBER OF STUD FEE PUPPY(IES): Owners of the stud dog and bitch should determine ahead of time what arrangement will be made should the bitch rear only one puppy and the breeding was effected for a stud fee puppy. On the appropriate litter application, indicate any STUD FEE puppy(ies) by checking only the box(es) next to a Stud Fee Puppy’s name(s). Each of the undersigned: a) certifies, represents, and warrants to the Cavalier King Charles Spaniel Club, USA, Inc. (CKCSC-USA) that all the information in this application is valid (i.e., true, accurate, complete, and not misleading); b) authorizes the CKCSC-USA to take such lawful steps as the CKCSC-USA, in its sole discretion, deems necessary or appropriate to investigate the validity or invalidity of any such information; c) irrevocably agrees that if any of such information is found to be invalid and the breeder(s) knew or should have known it was invalid, s/he shall defend, reimburse, indemnify, and hold the CKCSC-USA, and each of its Directors, employees, and other representatives harmless from any and all costs and expenses, including attorney fees, directly or indirectly caused by, resulting from or incurred in connection with such invalidity or investigation; d) agrees that the CKCSC-USA, by accepting this Stud Service Certificate, shall be entitled to the full benefits of the provisions set forth in this paragraph, whether or not the CKCSC-USA ever issues registration for this litter. I(we) hereby certify that I(we) authorized the breeding of the above-named stud dog to the above-named bitch. SIGNATURE OF STUD DOG OWNER: DATE: SIGNATURE OF STUD DOG CO-OWNER: DATE: I have included a SUPPLEMENTAL SIGNATURE FORM for ALL dogs with more than 2 owners. (Please see page 2 of this form for additional pertinent information.) O W N E R C O O W N E R S T U D B I T C H M A T I N G