This form will allow you to send the information, on line, to include your PWD on the Memorial Wall at the 2003 Specialty.

Your full name:

Your email address: (e.g.: you@aol.com). We will  notify you of the receipt of your form with this address.

Your phone number (with country, city, area codes):

Name of Portuguese Water Dog to be included:    

Date of birth:                 Date of death:           

Sire:    

Dam:   

I am sending a Picture     Yes    No  

Please send pictures to:  Karen Kelly, 7931 Claiborne Lane, Inver Grove Heights, MN  55076

Anything additional information you would like to supply?