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Breeders’ Event Registration

Name (Required) *

Number attending

Guests or Companions

Please list the names of everyone in your group.

Special Requests

Please list details about food allergies or special dietary requirements that you or someone in your party would like the organizers to know about.

NEMDA Member Information

Mailing Address Line 1

Address Line 2

City

State / Province / Region

AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundland & LabradorNorth CarolinaNorth DakotaNova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukonOther

Country

AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Postal / Zip Code

Contact Phone

Contact Email (Required) *

PLEASE make a selection from the following list: (Required) *

Breeders Seminar: BCOE Breeder or Partner – $25 (Includes lunch)Breeders Seminar: All others – $50 (no lunch)Breeders Seminar: All others – $65 (includes lunch)

National Specialty 2018 Rules and Agreement:

Agree to Hold Harmless (Required) *

I/we agree to assume any and all risk in connection with and arising out of my/our attendance at the NEMDA 2018 Annual Events. I/we also agree to indemnify NEMDA and to hold NEMDA harmless for any and all injuries, claims, losses, or causes of action in connection with and arising out of my/our attendance at these NEMDA Events, which indemnity shall include reimbursement of any attorneys\’ fees incurred by NEMDA in connection with the defense of any claim arising out of or relating to my/our attendance at these NEMDA Events.

I/we agree

(Required) *

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NOTE: When you click submit, this form will be emailed to the Breed Committee, a receipt will be emailed to the owner address above, and the information in the form will be cleared.

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