2022 Feisty Malinois Mondioring Club USMRA Trial Entry Form

USMRA TRIAL ENTRY FORM

Evergreen Mondioring & Spirit of Competition Clubs

April 8, 2023

Santa Rosa, CA

Handler Information
Handler's Name*

First Name Last Name
Handler's USMRA Member Number*
Handler's Phone Number

Area Code Phone Number
Handler's Mailing Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Handler's Email Address*
2023 USMRA Club Affiliation
Additional 2023 USMRA Club Affiliation
Have you or your competing dog ever been banned or suspended from ANY dog organization?*

YesNo
If yes, please explain
Dog Information
Dog's Registered Name*
Dog's Date of Birth*

MonthDay Year
Date
Dog's Sex*

MaleFemale
Spayed / Neutered?*

YesNo
Dog's Breed as listed in Scorebook*
Dog's Recall*

WhistleVoice
Dog's Scorebook # - Organization and Number*
FCI Titles Listed in Scorebook
Is Dog FCI Registered*

YesNo
Dog's FCI Registration Organization Name & Number*
Will dog be in heat during event?*
Before competing in any USMRA event, the dog must have a microchip or tattoo for identification purposes that will be verified by the hosting club.
Tattoo/Microchip Number*
Does Dog have a USMRA Issued Identification Card? If yes, please attach at the bottom of this form. If no, please complete the application for the USMRA Dog ID Card *

YesNo
Before competing in any USMRA event, the dog must have documentation of passing an approved Sociability Test. Sociability test type and date must be entered into the Dog's Scorebook and MUST be signed by a Judge.
Has the dog completed an approved Sociability Test?*

YesNo. Dog must pass a Sociability Test before competing.
Date of Sociability Test

MonthDay Year
Sociability Test Type - The only sociability tests accepted by USMRA are the 2016 USMRA Working Aptitude Sociability Test, Canine Good Citizen (AKC), BH (IPO), CSAU (French Ring). Dogs having other approved sociability tests administered prior to 7/2016 will be grandfathered in and accepted.*
Before competing in any USMRA event, the dog must have documentation of a current rabies vaccine.
Date of most current Rabies Vaccination*

MonthDay Year
How many years is the rabies vaccination good for?*

1 year2 years3 years
Dog Owner Information
Dog's Owner Name (if different than handler)

First Name Last Name
Dog's Owner Phone Number

Area Code Phone Number
Trial Entry Information - April 8, 2023 - Judge: Don Lee - Decoys: Zack Kiser and Anthony Sagstetter - Location: Santa Rosa, CA - Open Field: 4/7 at 9am - Theme: After Party
Hosting Club: Evergreen Mondioring Club
Entry Fees:

Sociability Test: $55.00

OB/OBJ: $55.00

Brevet, MR1, MR2, MR3: $55.00
Date of Competition

MonthDay Year
Additional Date of Competition

MonthDay Year
Level you are registering for:*

OB1OBJ1BrevetMR3OB2OBJ2MR1USMRA Sociability TestOB3OBJ3MR2
By submiting this form, I authorize USMRA and the hosting club, to use the following personal information:

(1) My picture - including photographic, motion picture and electronic (video) images.

(2) My voice - including sound and audio/video recordings

I hereby grant USMRA and the hosting club the right to use, publish and reproduce, for all purposes, my name, pictures of me in film or electronic (video) form, sound and video recordings of my voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media including, without limitation, cable and broadcast television and the Internet, and for exhibition, distribution, promotion, advertising, press conferences and in brochures and other printed media. This permission extends to all languages, media, formats and markets now known or hereafter devised.
* PLEASE READ CAREFULLY By submitting this application, I attest that this information is correct and true, to the best of my knowledge. I understand and I agree to abide by the USMRA Code of Conduct, rules and regulations of the USMRA (United States Mondioring Association), policies and procedures and it's stated purposes of promoting Mondioring, sportsmanlike conduct and fair and humane training at all dog sport activities. I agree to keep myself informed on current by-laws, and policies and procedures of USMRA via the www.usmondioring.org website, OFFICIAL communications, or by requesting a copy from the USMRA Secretary. It is hereby understood that every dog at this event will be under the direct care of its handler. The undersigned agrees to be fully responsible for any and all actions of themselves and their dog(s), including dogs owned by another, but in the undersigned's care. I agree to hold harmless all members, officers and directors of USMRA, the Hosting Club as listed above, and any property owners associated with this event in case of accident or injury. Any and all score protests will be submitted in writing to a member of the trial organizing committee at the event only. No protests will be heard after the closing ceremony, and all decisions concerning any protests will be made by the time of the closing ceremony and shall be final. I the undersigned do hereby verify that my dog(s) is/are healthy and current in his/her required vaccines, and I assume all responsibility and liability for myself and my dog(s).*

Agree
Signature*
Today's Date:*

MonthDay Year
Date
Select what area(s) you will be competing in at the trial. This will take you to PayPal for payment.*
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Sociability Test $55.00

Quantity

OB/OBJ $55.00

Quantity

Brevet, MR1, MR2, MR3 $55.00

Quantity

Total $0.00
Please provide a copy of USMRA issued Dog Identification Card
Please provide the following if your dog DOES NOT have a USMRA issued Dog Identification Card. You will need to complete a Dog Identification Application prior to trialing.
Please provide a copy of Sociability Test
Please provide a copy of Rabies Vaccination Certificate
Should be Empty:

Handler Information

Dog Information

Dog Owner Information

Trial Entry Information - April 8, 2023 - Judge: Don Lee - Decoys: Zack Kiser and Anthony Sagstetter - Location: Santa Rosa, CA - Open Field: 4/7 at 9am - Theme: After Party

Hosting Club: Evergreen Mondioring Club