CANINE DNA RESEARCH

LITTER INFORMATION Breed: ____________________

(attach Pedigree, and Litter List) Litter ID code: ______________

Breeder: ________________________________ Litter birthdate: _____________

Information Contact:(name) ___________________________________

(address) _________________________________

(city, state, zip) _____________________________

(phone-day) ______________________________

(phone-eve) ______________________________

(Fax) ___________________________________

(e-mail) __________________________________

Number of pups: - at birth - live M _____ F _____ dead M _____ F _____

- surviving at 6 weeks - M _____ F _____

- surviving at 6 months - M _____ F ______

- surviving at submission date - M _____ F _____

Color(s) present in litter: _______________________________________________

Known health problems in litter:

(List problem, dog name and ID # from litter list, age of onset, pertinent details)

Other litter notes or comments:

Submitted by (name) ________________________ on (date) __________________