Owners Information ______________________________________________________________________ Owners Name                       Phone #: Home           Alt. ______________________________________________________________________ Address                                  City                State       Zip Veterinarian Information ______________________________________________________________________ Clinic Name                   Veterinarian Name                  Veterinarian Phone Number ______________________________________________________________________ Address                                  City                State       Zip Dogs Information ______________________________________________________________________ Dogs Name                  Sex                  Registration #                  Date of Birth ______________________________________________________________________ Microchip #(Required)                                                   Certified Weight This is to certify that the Shih-Tzu being examined is over one year of age, in good general health and weighing under 9 pounds. The weight and size of the dog in question must be a natural size and with no reason to believe it may have stunted growth. ______________________________________________________________________ Owners Signature                                                             Date ______________________________________________________________________ Veterinarian Signature                                                        Date If these proper conditions apply, the Shih-Tzu in question may be registered as an Imperial Shih-Tzu by NADSR. Please mail your request and $6.00 to: North American Dog Sports and Registry P.O. Box 1136 Pine Grove, LA 70453 Phone: 225-777-4146 Cell: 225-938-5976 Email: k9@centurytel.net Website: www.nadsr.com