Owner/Agent Information:         Date:

Name:

Thank you for your contribution.  Your samples will be added to our database for the breed(s) you indicated.  As we are looking at breeds as a whole, results on individual cats will not be available.  We can, however, provide you with a copy of our research findings.  In our reports no cats or owners will be identified by name.

Address:

City:

State/ Prov:

Country:                                         Phone:

Email:

Registered Name of cat (no titles)

Reg & Reg #

Date of Birth

Sex (circle)

Breed

Titles

Color

Healthy

Registered Name of Sire & Dame (no titles)

 If possible please include pedigrees

M

F

Y

N

Sire:_________________________________________

Dam:

M

F

Y

N

Sire:_________________________________________

Dam:

M

F

Y

N

Sire:_________________________________________

Dam:

M

F

Y

N

Sire:_________________________________________

Dam:

M

F

Y

N

Sire_________________________________________

Dam:

M

F

Y

N

Sire:_________________________________________

Dam:

M

F

Y

N

Sire:_________________________________________

Dam:

M

F

Y

N

Sire:_________________________________________

Dam:

Please describe health history for unhealthy cats submitted:

I understand that results for individual cats will not be available

Signature:

____Please send me a copy of your final report