Leavitt Bulldog Association^© 2005

Application for Litter registration

Sire______________________________ Reg. #______________________
Dam______________________________ Reg. # _____________________
D.O.B. of litter to be registered ___________________ Number of puppies lost or stillborn ____
Breeder’s Name ____________________________ Kennel prefix (if desired) _________________
Address__________________________________ City__________________________State_______
Zip_____________ Telephone # _________________________

E-Mail Address (required) ______________________________

Please complete the entire form. The recording fee for litter registration is $15.00 U.S. per puppy for litters of 1 or
2 puppies or $30.00 U.S. for litters of 3 or more puppies.
Postal Check or Money Order only made payable to Mary Courville.

Personal checks cannot be accepted. Naming of individual puppies at this time is optional, but all other
information must be completed to assist in the future identification of the animal. Please print clearly.

Puppy Data - (Please list all puppies. Photos are not required, but may be submitted voluntarily.

Identify puppy with corresponding puppy # or name. Pictures should be E-mailed.)
*Pied on white are colored markings on a predominately white background – Please describe.

Puppy#____	Sex	Color		Jaw	Tail
	Circle one M F	Solid______ Brindle_____ *Pied on White	White___ Red___ Grey___ Black___ Fawn___ Other________________ _____________________	Wry Jaw (Crocked) Yes / No	Pump Handle___ Sight Crook ____ Serious Crook___ Cork Screw_____ Bobbed________

Puppy#____	Sex	Color		Jaw	Tail
	Circle one M F	Solid______ Brindle_____ *Pied on White	White___ Red___ Grey___ Black___ Fawn___ Other________________ _____________________	Wry Jaw (Crocked) Yes / No	Pump Handle___ Sight Crook ____ Serious Crook___ Cork Screw_____ Bobbed________

Puppy#____	Sex	Color		Jaw	Tail
	Circle one M F	Solid______ Brindle_____ *Pied on White	White___ Red___ Grey___ Black___ Fawn___ Other________________ _____________________	Wry Jaw (Crocked) Yes / No	Pump Handle___ Sight Crook ____ Serious Crook___ Cork Screw_____ Bobbed________

Page 2

Puppy#____	Sex	Color		Jaw	Tail
	Circle one M F	Solid______ Brindle_____ *Pied on White	White___ Red___ Grey___ Black___ Fawn___ Other________________ _____________________	Wry Jaw (Crocked) Yes / No	Pump Handle___ Sight Crook ____ Serious Crook___ Cork Screw_____ Bobbed________

Puppy#____	Sex	Color		Jaw	Tail
	Circle one M F	Solid______ Brindle_____ *Pied on White	White___ Red___ Grey___ Black___ Fawn___ Other________________ _____________________	Wry Jaw (Crocked) Yes / No	Pump Handle___ Sight Crook ____ Serious Crook___ Cork Screw_____ Bobbed________

Puppy#____	Sex	Color		Jaw	Tail
	Circle one M F	Solid______ Brindle_____ *Pied on White	White___ Red___ Grey___ Black___ Fawn___ Other________________ _____________________	Wry Jaw (Crocked) Yes / No	Pump Handle___ Sight Crook ____ Serious Crook___ Cork Screw_____ Bobbed________

Puppy#____	Sex	Color		Jaw	Tail
	Circle one M F	Solid______ Brindle_____ *Pied on White	White___ Red___ Grey___ Black___ Fawn___ Other________________ _____________________	Wry Jaw (Crocked) Yes / No	Pump Handle___ Sight Crook ____ Serious Crook___ Cork Screw_____ Bobbed________

(If you have more pups then spaces on the form, print extra of Page 2)

I ________________________ certify that I am the breeder of this litter of Leavitt Bulldogs, and affirm that
the above information is true and correct.

Signature___________________________________ Date__________________________

Leavitt Bulldog Association Registrations

Mary Courville

186 Victor Rd.

Rayne, LA 70578