Golden State German Shepherd Dog Club of San Jose. Fremont Central Park Paseo Padre Parkway, Fremont, CA 94538

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Premium List Golden State German Shepherd Dog Club of San Jose CONFORMATION JUNIOR SHOWMANSHIP (SUN ONLY) 4-6 MONTHS BEGINNER PUPPY (SUN ONLY) SATURDAY, JANUARY 12, 2019 - AM EVENT # 2019114001 SATURDAY, JANUARY 12, 2019 - PM EVENT # 2019114002 SUNDAY, JANUARY 13, 2019 EVENT # 2019114003, 2019114004 Fremont Central Park 40000 Paseo Padre Parkway, Fremont, CA 94538 Unbenched and Outdoors Regardless of Weather Event hours: 8:00 am. To 5:00 pm Consult Judging Program for Time of Judging Licensed Show CERTIFICATION Permission has been granted by the American Kennel Club for the holding of this event under American Kennel Club rules and regulations. Gina M. Dinardo, Secretary Officers President... Jene Dupzyk Vice President... Eric Norby Treasurer... Joan Intersimone Secretary... Ben Bigornia... 4970 Bosworth Ct, Newark, CA 94560 Directors Deborah Hopkins, Stephanie Frentz, Jessica Plunk, Karen Toth Show Committee Show Chair... Ben Bigornia... 4970 Bosworth Ct., Newark, CA 94560 Trophy Chair... Joan Intersimone Grounds Chair... Ben Bigornia, Eric Norby Hospitality Chair... Jene Dupzyk Ribbons... Joan Intersimone Premium List... Joan Intersimone Catalog... Connie Horvath Chief Conformation Steward... Kay Springer Officers, Directors & Committee Members will serve on the Bench Show Committee SHOW SECRETARY Karen Toth, 7825 Cranford Lane, Dublin CA 94568 (925) 829-1535 - Fax (925) 687-1127 gsdshowsec@sbcglobal.net Make checks payable to Golden State GSDCSJ There will be a $2.00 convenience fee per dog when using PayPal for payment of hand delivered, faxed or mailed entries. For information about PayPal payments, please email gsdshowsec@sbcglobal.net. Fax service (925) 687-1127 These shows are dedicated to the memory of Isabelle A. Dupzyk, longtime member and friend CONFORMATION AND JUNIOR SHOWMANSHIP ENTRIES CLOSE SATURDAY DECEMBER 29, 2018, 8:00 PM LOCAL TIME 4-6 MONTH BEGINNER PUPPY ENTRIES CLOSE SUNDAY JANUARY 13, 2019 AT 9:00 AM LOCAL TIME Page 1 Page 2

JUDGES Mr. Robert Drescher... 500 Dogwood Dr. York, PA 17406 Mr. LaMar Frederick... 3254 Deer Creek Dr. Lambertville, MI 48144 Mrs. Jennifer Root... 483 Peach Tree Dr. SE, White GA 30184 Judging Assignments Saturday AM Saturday PM Sunday Conformation J. Root R. Drescher L. Frederick Junior Showmanship (not offered) (not offered) L. Frederick 4-6 Months Beginner Puppy (not offered) (not offered) J. Root ENTRY FEES All entries include $.50 AKC recording fee and $3.00 AKC Event Fee. Conformation Fees: All Regular Classes (except Puppy, Bred-By & Veteran Classes) 6-9 Puppy, 9-12 Puppy, Bred-By Classes.. Additional entry of same dog (same day)...... Veteran Classes. Junior Showmanship.. 4-6 Month Beginner Puppy (Sunday Only.. $ 30.00 $ 20.00 $ 20.00 $ 10.00 n/c $ 10.00 Returned checks do not constitute a valid entry fee. A $25 collection fee will be assessed for all returned checks. CONFORMATION CLASSIFICATION Regular Breed Classes Classes offered for each sex: 6 months and under 9 months Puppy 9 months & under 12 months Puppy Twelve to Eighteen months Novice Bred by Exhibitor * American Bred Open Winners Best of Breed Bred by Exhibitor Class Eligibility: 1) All dogs entered in the Bred by Exhibitor class must be individually registered with the AKC, 2) the person handling the dog must be a breeder of record of the dog and an owner of record of the dog. EXHIBITOR RULE CHANGE EFFECTIVE 01/01/2011 Chapter 11, Section 1. No dog shall be exhibited in a licensed or member dog show, except for dogs entered in the Miscellaneous Class unless it is either individually registered in the AKC Stud Book, or individually registered with a foreign registry organization whose pedigrees are acceptable for AKC registration. For complete details see Rules Applying to Dog Shows, Chapter 11, Section 1. Non-Regular Classes PRE-PAID CATALOGS A very limited number of catalogs will be for sale at the show. PLEASE SEND $5.00 WITH YOUR ENTRY FEES TO PURCHASE YOUR CATALOG. Classes offered for each sex: Veteran Classes: For dogs or bitches seven (7) years of age or older on the day of the show. Neutered dogs and spayed bitches may compete in the Veterans Class. 1 st Veteran dog & 1 st Veteran Bitch compete for Best of Breed. PLEASE NOTE NEW MAILING ADDRESS FOR ENTRIES JUNIOR SHOWMANSHIP CLASSIFICATION SUNDAY ONLY Novice Classes: For children who, at the time entries close, have not won three First Places in a Novice Class at a licensed or member show. Open Classes: For children who, at the time entries close, have won three First Places in a Novice Class at a licensed or member show. Master Classes: For children who, at the time entries close, have won the 10 first place wins in an Open class with competition. Best Junior Handler: Winners from each class will compete for Best Junior Handler. Page 3 Page 4

4-6 MONTH BEGINNER PUPPY Closing date and time for 4-6 Month Beginner Puppy will be Sunday January 13, 2019 at 9:00 AM The Four-to-Six Month Puppy competition shall be for dogs that are four months of age and over but under six months on the day of the event. AKC registration number or an AKC litter number will be required for entries of an AKC recognized breed as listed in Chapter 3, Section 1 of the Rules Applying to Dog Shows. A foreign-born dog may enter this class if they are registered in the country of origin Professional handlers are not permitted to exhibit in this class. Dogs that are owned or co-owned by a professional handler may compete in this class, but must be handled by a non-professional handler. All of the puppies of the same breed (not divided by sex) are exhibited in the same class and the only placements are Best of Breed and Best of Opposite Sex to Best of Breed RIBBON PRIZES AND SPECIAL TROPHIES Regular Classes First Prize: Blue Ribbon Second Prize: Red Ribbon Third Prize: Yellow Ribbon Fourth Prize: White Ribbon Winners: Purple Rosette Reserve Winners: Purple & White Rosette Best of Winners: Blue & White Rosette Best of Opposite Sex to Best of Breed: Red & White Rosette Best of Breed: Purple & Gold Rosette Grand Champion Select: Light Blue & White Ribbon Non-Regular Classes & Jr. Showmanship First Prize: Rose Ribbon Second Prize: Brown Ribbon Third Prize: Light Green Ribbon Fourth Prize: Gray Ribbon Best Puppy: Green Rosette Best of Opposite Sex Puppy: Green & White Rosette Best Junior Handler: Rose & Green Ribbon Best 4-6 Month Puppy: Orange Ribbon Best of Opposite Sex 4-6 Month Puppy: Lavender Ribbon Special Awards & Trophies GSDCA BRONZE MEDALION WILL BE OFFERED FOR: Best of Breed Saturday AM and PM and Sunday Special Trophies Saturday AM and PM First place in all regular classes... Club Medallion Winners Dog and Winners Bitch... Stainless Steel Pail & Plush Dog Toy Reserve Winners Dog and Reserve Winners Bitch... Stainless Steel Pail Best of Breed... Flexrake Large Scoop Set Best of Winners... Plush Dog Toy Best of Opposite Sex... Stainless Steel Pail Best Puppy... Dog Treat Jar Best of Opposite Sex Puppy... Dog Treat Jar Sunday First place in all regular classes... Club Medallion Winners Dog and Winners Bitch... Stainless Steel Pail & Plush Dog Toy Reserve Winners Dog and Reserve Winners Bitch... Stainless Steel Pail Best of Breed... Flexrake Large Scoop Set Best of Winners... Plush Dog Toy Best of Opposite Sex... Stainless Steel Pail Best Puppy... Dog Treat Jar Best of Opposite Sex Puppy... Dog Treat Jar Best of Breed 4-6 Month Beginner Puppy... Dog Treat Jar Best of Opposite Sex 4-6 Month Beginner Puppy... Dog Treat Jar PHOTOGRAPHER Terry Cochran - Home: 541-280-7727, Text: 541-419-1497 Photos hosted by TCFOTO.Zenfolio.com Email: Tinky91147@gmail.com VETERINARIAN ON CALL Beacon Veterinary Specialists 1618 Washington Blvd. Fremont, CA 94539 (510) 657-6343 Page 5 Page 6

CATALOG ADVERTISING Full Page $10.00 Make checks payable to Golden State GSDCSJ Questions or more information, contact Joan Intersimone 925-286-6976 gsdmum@sbcglobal.net Deadline for catalog ads Sunday, January 6, 2019 MOTELS IN THE AREA The Best Western Garden Court Inn Phone: 510-792-4300 5400 Mowry Avenue Fremont, CA 94538 USA La Quinta Inn & Suites Fremont Phone: 510-445-0808 46200 Landing Parkway Fremont, California 94538-6463 Motel 6 Newark Phone: 510-791-5900 5600 Cedar Court Newark, CA 94560 AIRPORT(S): San Jose, Oakland and San Francisco International Fremont Central Park, 40000 Paseo Padre Pkwy, Fremont, CA 94538 RULES OF THE GOLDEN STATE GSDC of SAN JOSE 1. IF MONEY IS OWED TO GOLDEN STATE GERMAN SHEPHERD DOG CLUB OF SAN JOSE, ENTRIES AND PERSONAL CHECKS WILL NOT BE ACCEPTED UNTIL ALL MONEY OWED IS REMITTED BY MONEY ORDER OR CASHIERS CHECK. RETURNED CHECKS DO NOT CONSTITUTE A VALID ENTRY. 2. The club assumes no responsibility for a wrong entry. Please PRINT or TYPE all information on entry blanks. 3. During the hours of judging, owners are to be on call and to have their dog ready to be brought into the judging ring promptly so the judging will not be delayed. 4. It is the responsibility of the exhibitor to have his or her dog ready to be shown and at the entrance of the judging ring when the steward calls for the class. Owners of dogs or the handlers of the dogs are alone responsible for the presence of their dogs in the judging rings. 5. There is no rule of this Club or of the AKC that requires a judge to wait for an owner or handler to bring his or her dog into the ring. 6. An exhibitor whose dog is eligible for an award must be present or have an appointed representative to accept the award for him or her. 7. Entry fees will not be refunded if the dog is absent, disqualified, sick, lame, in season, excused by veterinarian or judge, or barred from competition by action of the show committee. 8. Exhibitors and handlers will be held responsible for clean conditions in and around their crates. 9. The welfare of an exhibitor s child is assumed to be the responsibility of the exhibitor. It is understood that the exhibitor will exercise control over his or her children on the day of the show. 10. The Club assumes no responsibility for dogs or equipment left unattended. 11. All dogs must be kept on leash. Point Schedule - Division 9 Effective May 16, 2018 1 Point 2 Points 3 Points 4 Points 5 Points Dogs 2 6 9 12 17 Bitches 2 5 8 13 21 NO OVERNIGHT PARKING AT THE SHOW SITE Page 7 Page 8

AKC Rules, Regulations, Policies and Guidelines are available on the American Kennel Club Web site, www.akc.org AGREEMENT I (we) agree that the club holding this event has the right to refuse this entry for cause which the club shall deem sufficient. 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, ribbons, or trophies, I (we) agree to hold the AKC, the event-giving 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 AKC 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 persons. I (WE) AGREE THAT ANY CAUSE OF ACTION, CONTROVERSY OR CLAIM ARISING OUT OF OR RELATED TO THE ENTRY, EXHIBITION OR ATTENDANCE AT THE EVENT BETWEEN THE AKC AND THE EVENT- GIVING CLUB (UNLESS OTHERWISE STATED IN ITS PREMIUM LIST) AND MYSELF (OURSELVES) OR AS TO THE CONSTRUCTION, INTERPRETATION AND EFFECT OF THIS AGREEMENT SHALL BE SETTLED BYARBITRATION PURSUANT TO THE APPLICABLE RULES OF THE AMERICAN ARBITRATION ASSOCIATION. HOWEVER, PRIOR TO ARBITRATION ALL APPLICABLE AKC BYLAWS, RULES, REGULATIONS AND PROCEDURES MUST FIRST BE FOLLOWED AS SET FORTH IN THE AKC CHARTER AND BYLAWS, RULES, REGULATIONS, PUBLISHED POLICIES AND GUIDELINES. INSTRUCTIONS 1. (Variety) if you are entering a dog of a breed in which there are varieties for show purposes, please designate the particular variety you are entering i.e., Cocker Spaniel (solid color black, ASCOB, particolor). Beagles (not exceeding 13 in. over 13 in. but not exceeding 15 in.). Dachshunds (longhaired, smooth, wirehaired), Collies (rough, smooth), Bull Terriers (colored, white), Manchester Terriers (standard, toy), Chihuahuas (smooth coat, long coat), English Toy Spaniels (King Charles and Ruby, Blenheim and Prince Charles), Poodles (toy, miniature, standard), 2. The following categories of dogs may be entered and shown in Best of Breed competition; Dogs that are Champions of Record and dogs which according to their owners records, have completed the requirements for a championship, but whose championships are unconfirmed. The showing of unconfirmed Champions in Best of Breed competition is limited to a period of 90 days from the date of the show where the dog completed the requirements for a championship. 3. (Event Class) Consult the classification in this premium list. If the event class in which you are entering your dog is divided, then, in addition to designating the class, specify the particular division of the class in which you are entering your dog, i.e., age division, color division, weight division. 4. A dog must be entered in the name of the person who actually owned it at the time entries for an event closed. If a registered dog has been acquired by a new owner, it must be entered in the name of its new owner in any event for which entries closed after the date of acquirement, regardless of whether the new owner has received the registration certificate indicating that the dog is recorded in his name. State on entry form whether transfer application has been mailed to A.K.C. (For complete rule refer to Chapter 11, Section 3). JUNIOR SHOWMANSHIP If this entry is for Jr. Showmanship, please give the following information: AKC JR HANDLER #: JR. S DATE OF BIRTH: The above number MUST be included. Should you not have your Junior Handler number, this may be obtained from the American Kennel Club. Phone: (919) 816-3776 By signing the entry form I (we) certify that the Junior Showman does not now, and will not at any time, act as an agent/handler for pay while continuing to compete in Junior NAME OF JR. HANDLER ADDRESS If Jr. Handler is not the owner of the dog identified on the face of this form, what is the relationship of the Jr. Handler to the owner? OFFICIAL AMERICAN KENNEL CLUB ENTRY FORM Golden State GSDC of San Jose Saturday, January 12, 2019 - AM Event #2019114001 Saturday, January 12, 2019 - PM Event #2019114002 Sunday, January 13, 2019 EVENT #2019114003, 2019114004 Entries Close Saturday, December 29, 2018, 8:00 PM Local Time I enclose $ for Entry Fees. I enclose $ for # Catalog Refer to page 2 for fee schedule. Make checks payable to Golden State GSDC of San Jose Mail all entries to Karen Toth, 7825 Cranford Lane, Dublin CA 94568 IMPORTANT: Read carefully instructions on reverse side before filling out. Numbers in the boxes indicate sections of the instructions relevant to the information needed in that box. BREED GSD VARIETY: (1) SEX DOG SHOW CLASS (2)(3) BEGINNER PUPPY 4 TO UNDER 6 MONTHS SWEEPSTAKES CLASS OBEDIENCE TRIAL CLASS JR. SHOWMANSHIP CLASS ADDITIONAL CLASSES NAME OF JUNIOR HANDLER (see back) JR. HANDLER AKC # FULL NAME OF DOG AKC Reg. No. FOREIGN REG. NO. & COUNTRY BREEDER SIRE DAM ACTUAL OWNER(S)[4] OWNER S ADDRESS DATE OF BIRTH PLACE OF BIRTH USA Canada Foreign Do not print the above in catalog NAME OF OWNER S AGENT (IF ANY) AT THE SHOW 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 above. In consideration of the acceptance of this entry, I (we) agree to abide by the rules and regulations of the American Kennel Club in effect at the time of this show or obedience trial, and by any additional rules and regulations appearing in the premium list for this show or obedience trial or both, and further agree to be bound by the "Agreement" printed on the reverse side of this entry form. I (we) certify and represent that the dog entered is not a hazard to persons or other dogs. This entry is submitted for acceptance on the foregoing representation and agreement. By signing the entry form we certify that the Junior Showman does not now, and will not at any time, act as an agent/handler for pay while continuing to compete in Junior SIGNATURE of owner or his agent duly authorized to make this entry TELEPHONE EMAIL ADDRESS Please print legibly

AKC Rules, Regulations, Policies and Guidelines are available on the American Kennel Club Web site, www.akc.org AGREEMENT I (we) agree that the club holding this event has the right to refuse this entry for cause which the club shall deem sufficient. 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, ribbons, or trophies, I (we) agree to hold the AKC, the event-giving 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 AKC 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 persons. I (WE) AGREE THAT ANY CAUSE OF ACTION, CONTROVERSY OR CLAIM ARISING OUT OF OR RELATED TO THE ENTRY, EXHIBITION OR ATTENDANCE AT THE EVENT BETWEEN THE AKC AND THE EVENT- GIVING CLUB (UNLESS OTHERWISE STATED IN ITS PREMIUM LIST) AND MYSELF (OURSELVES) OR AS TO THE CONSTRUCTION, INTERPRETATION AND EFFECT OF THIS AGREEMENT SHALL BE SETTLED BYARBITRATION PURSUANT TO THE APPLICABLE RULES OF THE AMERICAN ARBITRATION ASSOCIATION. HOWEVER, PRIOR TO ARBITRATION ALL APPLICABLE AKC BYLAWS, RULES, REGULATIONS AND PROCEDURES MUST FIRST BE FOLLOWED AS SET FORTH IN THE AKC CHARTER AND BYLAWS, RULES, REGULATIONS, PUBLISHED POLICIES AND GUIDELINES. INSTRUCTIONS 1. (Variety) if you are entering a dog of a breed in which there are varieties for show purposes, please designate the particular variety you are entering i.e., Cocker Spaniel (solid color black, ASCOB, particolor). Beagles (not exceeding 13 in. over 13 in. but not exceeding 15 in.). Dachshunds (longhaired, smooth, wirehaired), Collies (rough, smooth), Bull Terriers (colored, white), Manchester Terriers (standard, toy), Chihuahuas (smooth coat, long coat), English Toy Spaniels (King Charles and Ruby, Blenheim and Prince Charles), Poodles (toy, miniature, standard), 2. The following categories of dogs may be entered and shown in Best of Breed competition; Dogs that are Champions of Record and dogs which according to their owners records, have completed the requirements for a championship, but whose championships are unconfirmed. The showing of unconfirmed Champions in Best of Breed competition is limited to a period of 90 days from the date of the show where the dog completed the requirements for a championship. 3. (Event Class) Consult the classification in this premium list. If the event class in which you are entering your dog is divided, then, in addition to designating the class, specify the particular division of the class in which you are entering your dog, i.e., age division, color division, weight division. 4. A dog must be entered in the name of the person who actually owned it at the time entries for an event closed. If a registered dog has been acquired by a new owner, it must be entered in the name of its new owner in any event for which entries closed after the date of acquirement, regardless of whether the new owner has received the registration certificate indicating that the dog is recorded in his name. State on entry form whether transfer application has been mailed to A.K.C. (For complete rule refer to Chapter 11, Section 3). JUNIOR SHOWMANSHIP If this entry is for Jr. Showmanship, please give the following information: AKC JR HANDLER #: JR. S DATE OF BIRTH: The above number MUST be included. Should you not have your Junior Handler number, this may be obtained from the American Kennel Club. Phone: (919) 816-3776 By signing the entry form I (we) certify that the Junior Showman does not now, and will not at any time, act as an agent/handler for pay while continuing to compete in Junior NAME OF JR. HANDLER ADDRESS If Jr. Handler is not the owner of the dog identified on the face of this form, what is the relationship of the Jr. Handler to the owner? OFFICIAL AMERICAN KENNEL CLUB ENTRY FORM Golden State GSDC of San Jose Saturday, January 12, 2019 - AM Event #2019114001 Saturday, January 12, 2019 - PM Event #2019114002 Sunday, January 13, 2019 EVENT #2019114003, 2019114004 Entries Close Saturday, December 29, 2018, 8:00 PM Local Time I enclose $ for Entry Fees. I enclose $ for # Catalog Refer to page 2 for fee schedule. Make checks payable to Golden State GSDC of San Jose Mail all entries to Karen Toth, 7825 Cranford Lane, Dublin CA 94568 IMPORTANT: Read carefully instructions on reverse side before filling out. Numbers in the boxes indicate sections of the instructions relevant to the information needed in that box. BREED GSD VARIETY: (1) SEX DOG SHOW CLASS (2)(3) BEGINNER PUPPY 4 TO UNDER 6 MONTHS SWEEPSTAKES CLASS OBEDIENCE TRIAL CLASS JR. SHOWMANSHIP CLASS ADDITIONAL CLASSES NAME OF JUNIOR HANDLER (see back) JR. HANDLER AKC # FULL NAME OF DOG AKC Reg. No. FOREIGN REG. NO. & COUNTRY BREEDER SIRE DAM ACTUAL OWNER(S)[4] OWNER S ADDRESS DATE OF BIRTH PLACE OF BIRTH USA Canada Foreign Do not print the above in catalog NAME OF OWNER S AGENT (IF ANY) AT THE SHOW 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 above. In consideration of the acceptance of this entry, I (we) agree to abide by the rules and regulations of the American Kennel Club in effect at the time of this show or obedience trial, and by any additional rules and regulations appearing in the premium list for this show or obedience trial or both, and further agree to be bound by the "Agreement" printed on the reverse side of this entry form. I (we) certify and represent that the dog entered is not a hazard to persons or other dogs. This entry is submitted for acceptance on the foregoing representation and agreement. By signing the entry form we certify that the Junior Showman does not now, and will not at any time, act as an agent/handler for pay while continuing to compete in Junior SIGNATURE of owner or his agent duly authorized to make this entry TELEPHONE EMAIL ADDRESS Please print legibly