Register of Merit (ROM) Program Application

Applying for*

Candidate Border Collie Information

Candidate's

Registered Name:	Call Name	Gender	AKC #	Date of Birth	Color

If no longer living, Date of Death Required

Breeder's Name*

First Last

Candidate's Sire Reg Name and AKC #:

Reg Name	AKC #

Candidate's Dam Reg Name and AKC #:

Reg Name	AKC #

Owner Information

Note: You may list co-owners, but give only one address to which the certificate will be sent.

Primary Owner Name*

First Last

Co-owner Name 1

First Last

Co-owner Name 2

First Last

Primary Owner Street*

Primary Owner City/State/Zip*

Primary Owner Best Telephone*

Primary Owner Email*

Primary Best Way to Contact*

Candidate's Offspring Information

NOTE: If number of litters exceeds five, complete information for first five litters, submit form and see link on confirmation page for additional litters.

LITTER 1: Whelp Date*

Litter 1: Bred-To Name/AKC#*

Name	AKC #

LITTER 1: List Registered Name, AKC #, and AKC Titles for each offspring in the litter.

LITTER 2: Whelp Date

Litter 2: Bred-To Name/AKC#

Name	AKC #

LITTER 2: List Registered Name, AKC #, and AKC Titles for each offspring in the litter.

LITTER 3: Whelp Date

Litter 3: Bred-To Name/AKC#

Name	AKC #

LITTER 3: List Registered Name, AKC #, and AKC Titles for each offspring in the litter.

LITTER 4: Whelp Date

Litter 4: Bred-To Name/AKC#

Name	AKC #

LITTER 4: List Registered Name, AKC #, and AKC Titles for each offspring in the litter.

LITTER 5: Whelp Date

Litter 5: Bred-To Name/AKC#

Name	AKC #

LITTER 5: List Registered Name, AKC #, and AKC Titles for each offspring in the litter.

Additional Litters

Please list all additional litters beyond five in this box, including the same information as in the previous litters listed.