SMBC IGP Entry Form

Southern Minnesota Boxer Club Entry Form
Handler Name*

First NameLast Name
Handler Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Club Affiliation *
Membership #*
Phone Number*
E-mail*
Dog Information
Handler Owner Trained*
Registered Name of Dog*
Call Name of Dog*
Breed of Dog*
Date of Birth- mm/dd/yyyy*
Sex of Dog*
Dogs Current Titles
Club BH Earned
Not Required for new BH Handlers
Date BH Earned

MonthDayYear
Date
Intact or Altered*
Score Book #*
Score Book Type *
Reg. Organization*
i.e AKC, etc.
Reg #*
Org. #
Tattoo# and or Microchip #*
Owner Information
FILL OUT ONLY IF DIFFERENT THAN HANDLER
Owner Name

First NameLast Name
Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Organization
Owner's Org. #
Payment
I certify that I am the actual owner of the dog, or that I am the duly authorized agent of the actual owner whose name I have entered. In consideration of the acceptance of this entry, I (we) agree to abide by the rules and regulations of SMBC/USA-BOX/AWDF at the time of this event, and any decision made in accord with them. I (we) agree that the club holding this event has the right to refuse this entry for cause which the club shall deem sufficient. I (we) certify and represent that the dog entered is not a hazard to persons or other dogs. In consideration of the acceptance of this entry and of the holding of this event and of the opportunity to have the dog judged and to win prizes or trophies, I (we) agree to hold Southern Minnesota Boxer Club, their members, directors, governors, officers, agents, superintendents or event secretary and the owner and/or lessor of the premises and any provider of services that are necessary to hold this event and any employees or volunteers of the aforementioned parties, and any approved judge, judging at this event, harmless from any claim for loss or injury which may be alleged to have been caused directly or indirectly to any person or thing by the act of this dog while in or about the event premises or grounds or near any entrance thereto, and I (we) personally assume all responsibility and liability for any such claim; and I (we) further agree to hold the aforementioned parties harmless from any claim for loss, injury or damage to this dog.

Additionally, I (we) hereby assume the sole responsibility for and agree to indemnify, defend and save the aforementioned parties harmless from any and all loss and expense (including legal fees) by reason of the liability imposed by law upon any of the aforementioned parties for damage because of bodily injuries, including death at any time resulting therefrom, sustained by any person or persons, including myself (ourselves), or on account of damage to property, arising out of or in consequence of my (our) participation in this event, however such, injuries, death or property damage may be caused, and whether or not the same may have been caused or may be alleged to have been caused by the negligence of the aforementioned parties or any of their employees, agents, or any other person.
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Membership Card Cancelof
$85: IGP1, IGP2, IGP3, GPr1, GPr2, GPr3

$75: BH-VT, UPr1, UPr2, UPr3, FPr1, FPr2, FPr3
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BH-VT$75.00

IFH-V$75.00

IGP$85.00

IGP Level

FPR$75.00

FPR Level

GPR$85.00

GPR Level

UPR$75.00

UPR Level

Total $0.00
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Southern Minnesota Boxer Club Entry Form

Dog Information

Owner Information

Payment