Premium List THREE DAYS 4 ALL- BREED OBEDIENCE 5 ALL- BREED RALLY TRIALS This event is Accepting Entries for All-American Dogs Enrolled in the AKC Canine Partners Program Obedience Trial - #2018249309 Rally Trial - # 2018249308 Friday, August 3, 2018 Obedience Trials - #2018249310 & 2018249312 (Limited to 8 hours each) Rally Trials - # 2018249313 & 2018249314 Saturday, August 4, 2018 Obedience Trial - #2018249316 Rally Trials - # 2018249311 & 2018249315 Sunday, August 5, 2018 Springfield Missouri Dog Training Club Officers PRESIDENT...................................... David Casada VICE-PRESIDENT............................... Ladina Vanzandt TREASURER.................................... Kim Spradling SECRETARY....................................... Tony Hahn 3636 S. Nettleton Ave., Springfield, MO 65807 Board of Directors, Vicki Goodin, Pam Kennedy TRAINING DIRECTOR............................... Lorri Sheets Trial Chairperson Trial Secretary Judith Walker 8758 S Chrissy Ln. 2251 Hwy TT Fair Grove, MO 65648 St. Clair, MO 63077 417-209-0961 VM: 636-486-6361 ksisco78@gmail.com studiohillk9.eventsecretary@gmail.com SPRINGFIELD, MO DOG TRAINING CLUB www.smdtc.org LAKE COUNTRY SOCCER DOME 2334 E. Pythian Springfield, MO 65802 Held Indoors Climate controlled on Soccer Turf ENTRIES CLOSE at 6:00 pm Central, Wednesday July 18, 2018 After which time entries cannot be accepted, canceled, altered, or substituted except as provided for in Chapter 11, Section 6 of the Dog Show Rules American Kennel Club Certification Permission has been granted by the American Kennel Club for holding this event under American Kennel Club Rules and Regulations. Gina DiNardo, Secretary Trophy Hospitality Match Chair Publicity Emergency Coordinator Robert Burgin #1881 Randy Capsel #20113 Lynn Eggers #0583 Committees Susan Casady Cathy Hawkins, Ladina Vanzandt Judges 3118 Bayberry Dr. SW, Cedar Rapids, IA 52404 586 190 th St., Ogden, IA 50212 3216 Wintergreen Terr., Grapevine, TX 76051 Trial Veterinarian - On Call Friday Carlson Pet Hospital 417-831-2666 311 W. Sunshine, Springfield MO 65807 Saturday & Sunday Emergency Vet Clinic of SW Missouri 417-890-1600 400 S Glenstone Ave., Springfield, MO 65802
3 Rent-A-Ring OC Matches Thu Aug 2 sign up 4:00 4:15pm - 6:30 Fri Aug 3 sign up by 2:30 15min after OB trial until 6:00 Sat Aug 4 sign up by 2:30 15min after OB trial until 6:00 Entries will be taken only on the day of the match 3 rings Novice - Open - Utility $10 for 10 minutes Match Chair & Secretary: 417-209-0961 ksisco78@gmail.com New Titles A rosette is offered to any dog finishing an Obedience or Rally title at these trials Catalogs are PRE ORDER ONLY Include $3 for you catalog with your entry Notice to Exhibitors The Trial Secretary is not responsible for emails not received. If you have not received a response to an email after 24 hours, please call the Trial Secretary by telephone. The safety of the dogs is our primary concern. By entering these trials, exhibitors acknowledge that they are familiar with the rules and regulations of this sport. Entry fees will not be refunded in the event that a dog is absent, disqualified, excused, or barred from competition by action of the Trial Committee. Entry fees will not be refunded if the trials cannot be opened or completed by reason of riots, civil disturbance, fire, an act of God, public emergency, an act of a public enemy, or any other cause beyond the control of the organizing committee. Entries must be made on Official AKC Entry Forms or copies and must include the signed Agreement and Rules. Junior Handlers must complete the back of the entry form. Please include only AKC titles on your entries. No entry shall be made and no entry shall be accepted which specifies any condition as to its acceptance. Entries will not be accepted without fees or signatures. Post Dated and Returned checks do not constitute a valid entry fee. There is a $25 returned check fee. Since bitches in season are not allowed to compete in AKC Obedience/Rally Trials, the club will refund all but $5.00 of the entry fee per day for bitches unable to compete for that reason. The Trial Secretary must receive written notification from a Veterinarian of such a claim not later than 30 minutes before the start of judging of the first class in the trial. It is expressly understood that exhibitors alone are responsible for the behavior of their dogs and/or children. Any exhibitor whose dogs and/or children create unnecessary disturbances or repeatedly engage in unsafe or disruptive behavior may, at the discretion of the Trial Committee, be asked to leave the trial site. In such case, no refund of any fees paid will be made. All dogs must be on lead or crated at all times except when in the ring. All warm ups MUST be done ON LEAD. That means the lead is attached to the dog s collar and the handler is holding the lead. Exhibitors are responsible for cleaning up after their dogs at show site and all hotel, motel, and campgrounds where they are staying while competing in these trials. Exhibitors are responsible for being at the ring gate when it is their turn to run. The judge need not wait for any dog holding up a class. Springfield MO Dog Training Club Inc. has no obligation or responsibility for providing service through a public address system or steward for the purpose of calling or locating dogs that are not brought to the ring when required. Owners are responsible for errors in making out entry forms, whoever may have made such errors. No entry will be refunded in the event of such errors or cancellation of entries after the published closing date. Errors in entries made by the exhibitor cannot be corrected after the closing date other than change from A to B with written request and move ups. No refunds for duplicate entries. Exhibitors should follow their veterinarians recommendation to assure their dogs are free of internal and external parasites, any communicable diseases, and have appropriate vaccinations. Springfield MO Dog Training Club, Inc., its Board, Members, and Lake County Soccer Dome and its employees will not be liable for any loss or injury which may be sustained through disappearance, loss, theft, communicable disease, parasites, injury and/or death of dogs entered in this event. Springfield MO Dog Training Club, Inc. does not agree to arbitrate claims as set forth on the Official AKC entry form for this event. Prizes will not be mailed. The Club reserves the right to substitute a prize of equal or greater value. Dogs under 6 months of age are not permitted on the show grounds of AKC Trials. Trial Information Site available to exhibitors at 3:30pm Thursday Aug 2. Trial hours are 7:30 am to 5:00 pm or end of Match. NO XPENS will be ALLOWED - Dogs may not be left overnight - No Un-Entered Dogs. The Trial Committee may require that the crate of any dog creating a disturbance in the crating area, through lunging, barking, growling, or other actions, be covered with opaque material. Trial Committee members may rearrange crates to maximize space if needed, including restricting placement of chairs in the crating area. Please crate in the specified areas. Your co-operation is appreciated. Bring your own chairs and water for your dog. Bitches in Season are not allowed on the show grounds. All dogs are to be kept on leash in compliance with the AKC rules. Dog s not allowed on Soccer Fields.
Obedience All classes will run TALL to SMALL all days Friday Saturday #1 Saturday #2 Sunday #1 Sunday #2 Novice A Lynn Eggers Robert Burgin Randy Capsel Randy Capsel Not Offered Novice B Lynn Eggers Robert Burgin Randy Capsel Randy Capsel Not Offered Open A Robert Burgin Robert Burgin Randy Capsel Lynn Eggers Not Offered Open B Robert Burgin Robert Burgin Randy Capsel Lynn Eggers Not Offered Utility A Robert Burgin Robert Burgin Randy Capsel Lynn Eggers Not Offered Utility B Robert Burgin Robert Burgin Randy Capsel Lynn Eggers Not Offered Optional & Alternative Beginner Novice A&B Graduate Novice Graduate Open Preferred Novice Preferred Open Rally Novice A & B Lynn Eggers Robert Burgin Randy Capsel Randy Capsel Not Offered Lynn Eggers Not Offered Not Offered Randy Capsel Not Offered Robert Burgin Not Offered Not Offered Lynn Eggers Not Offered Lynn Eggers Robert Burgin Randy Capsel Randy Capsel Not Offered Robert Burgin Robert Burgin Randy Capsel Lynn Eggers Not Offered Randy Capsel Lynn Eggers Lynn Eggers Robert Burgin Robert Burgin Intermediate Randy Capsel Lynn Eggers Lynn Eggers Robert Burgin Robert Burgin Advanced A & B Excellent A & B Randy Capsel Lynn Eggers Lynn Eggers Robert Burgin Robert Burgin Randy Capsel Lynn Eggers Lynn Eggers Robert Burgin Robert Burgin Masters Randy Capsel Lynn Eggers Lynn Eggers Robert Burgin Robert Burgin Transfers Transfers will be allowed at this trial per AKC Obedience Regulations, Chapter 1, Section 16a. Transfers close one half-hour prior to the start of each trial each day. Request must be in writing prior to the event. It is recommended that transfer requests be sent by email to the Trial Secretary prior to day of show. If an email address is provided with your request, an email confirmation will be sent. Classes Offered Obedience: Novice A & B, Open A & B, Utility A & B Beginner Novice A & B, Graduate Novice, Graduate Open Preferred Novice, Preferred Open Rally: Novice A & B, Intermediate, Advanced A & B, Excellent A & B, Masters Additional Premiums and Entry Forms are available at http://studiohillk9.com http://smdtc.org Entry Fees Payable to: Mail entries and fees to: SMDTC Judith Walker - SMDTC, 2251 HWY TT, ST. CLAIR, MO 63077 You must waive the signature requirement on all overnight deliveries. AKC Event & Recording Fees A Recording Fee of $0.50 cents and a $3.00 AKC Event Service Fee will be required for the first entry of each dog and a $3.00 Service Fee for each additional entry of the same dog in the regular and non-regular recordable single entry classes, in all AKC Licensed or Member Club Events. (Chapter 11, Section 2 of the Rules Applying to Dog Shows). A Recording Fee of $3.50 shall be required for the first entry of each dog and a Recording Fee of $3.00 shall be required for each additional entry of the same dog. (Chapter 1, Section 5 of Rally Regulations). Recording Fees and Event Service Fees are to be collected by the show-giving club and paid to the American Kennel Club. Entry Fees Includes the AKC recording and service fee Make checks payable to: SMDTC Entry fees must be paid in US funds. Obedience Classes First Entry of each dog in each EVENT In Regular and Optional Titling Classes........................ $28.00 Additional OBEDIENCE Entries of same dog, same EVENT......... $25.00 Rally Classes First Entry of each dog in each EVENT................................. $28.00 Additional RALLY Entries of same dog, same EVENT............. $25.00 Junior Handlers - with AKC JrH Number Each entry....................................................... $15.00 Entries must be signed and include the full page AGREEMENT on the back of (or attached to) the entry form. Incomplete entries are not valid and WILL BE RETURNED. Faxed entries are accepted; contact Trial Secretary FIRST for information before sending. How to Figure Total Entry Fees Owed Per Dog Each DAY and Each Trial #1 and Trial #2 are separate EVENTS. Obedience and Rally are separate EVENTS. Dogs entered in multiple EVENTS are required to pay First Entry fees for each EVENT. Entry for EACH EVENT First Obed Class Entry Additional Obed Class Entry First Rally Class Entry Additional Rally Class Entry Total for Friday Total For Saturday #1 Total for Saturday #2 Total for Sunday #1 Total for Sunday #2 Fee $28 $25 each $28 $25 each Fri Sat #1 Total Owed for All Entries $ Sat #2 Sun #1 Sun #2
Please verify pet policy when making reservations. Please check with the individual motel regarding their pet policy and fees. There are several new chain motels in the area. With it becoming more difficult to find motels that will accept pets, SMDTC appreciates exhibitors cooperation in picking up after their pets, crating dogs in the room, and being responsible dog owners. La Quinta South (No fee for pets ) - - - - - - - - - - - - - - - - - - - - 417-890-6060 2534 S. Campbell Ave., Springfield MO 65807 La Quinta Inn & Suites Airport Plaza - - - - - - - - - - - - - - - - - - - 417-447-4466 2445 Airport Plaza Ave., Springfield MO 65803 (Kearny and West By Pass) Arbor Suites - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 417-886-5090 1260 E. Independence St., Springfield MO 65807 Days Inn Battlefield/Hwy 65 - - - - - - - - - - - - - - - - - - - - - - - - - - 417-882-9484 3260 E. Montclair St., Springfield MO 65804 Drury Inn and Suites - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 417-863-8400 2715 N. Glenstone Ave., Springfield MO 65803 Quality Inn (Pet fee) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 417-889-6300 3330 E. Battlefield Rd., Springfield MO 65804 Directions to LAKE COUNTRY SOCCER DOME 2334 E. Pythian Springfield, MO 65802 From Hwy 65 North or South: Take Chestnut Expressway exit west to Patterson Street. Turn right on Patter and the soccer dome is on the corner of Patterson and Pythian. From I-44 West or East: Go south on Glenstone to Chestnut Expressway. Turn left on Pythian and the soccer dome is on the right at the corner of Pythian and Patterson. RV Parking There will be no overnight RV parking available at the trial site. The following are listed for your convenience, but please check with the individual campgrounds. There also may be other campgrounds in the area that accept pets. KOA Campground/Route 66 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 417-831-3645 5775 W. Farm Road 140, Springfield, MO 65802 Stafford RV Park- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 417-736-3382 313 Rte. 66, Strafford, MO 65757. FOOD There will be NO CONCESSIONS on site. Complementary coffee will be available each morning. There are a number of fast food restaurants in the area. In accordance with city ordinances, NO SMOKING is allowed inside the building.
Dogs Eligible to Enter This trial is open to all dogs over the age of 6 months that are registered with the American Kennel Club, including ILP/PAL registration, AKC Canine Partners listing number, and Approved FSS breeds, except bitches in season, aggressive dogs, or dogs suffering from any deformity, injury, or illness, which may affect a dog s physical or mental performance. Refer to Chapter 1 Section 14 of the Obedience Regulations for further restrictions. Refer to Chapter 2 of the Registration and Discipline Rules for the listing of registrable breeds that may participate. Jump Height Divisions for Rally Dog s Measured Height at Withers Height to be Jumped Less than 10 inches 4 10 to less than 15 8 15 to less than 20 12 Over 20 16 Jump Height Divisions for Obedience Dog s Measured Height at Withers Height to be Jumped Less than 7 ½ 4 / 8 7 ½ to 9 8 / 16 Greater than 9 to 11 10 / 20 Greater than 11 to 13 12 / 24 Greater than 13 to 15 14 / 28 Greater than 15 to 17 16 / 32 Greater than 17 to 19 18 / 36 Greater than 19 to 21 20 / 40 Greater than 21 to 23 22 / 44 Greater than 23 to 25 24 / 48 Greater than 25 to 27 26 / 52 Greater than 27 to 29 28 / 56 Greater than 29 to 31 30 / 60 Greater than 31 to 33 32 / 64 Greater than 33 to 35 34 / 68 Greater than 35 to 37 36 / 72 Regular & Optional Titling Classes First Prize - - - - - - - - - - - - - - - - - - - - - - - -Blue Ribbon Second Prize - - - - - - - - - - - - - - - - - - - - - Red Ribbon Third Prize - - - - - - - - - - - - - - - - - - - - - Yellow Ribbon Fourth Prize - - - - - - - - - - - - - - - - - - - - White Ribbon Ribbons & Rosettes Prizes Awarded Each Trial Unless otherwise indicated, the following prizes are offered by Springfield MO Dog Training Club, Inc. Prizes will not be mailed. The Club reserves the right to substitute a prize of equal or greater value. Qualifying Score is required to receive prizes in all classes. Obedience Awards & Prizes Highest Scoring Dog in Regular - Rosette Highest Scoring Dog in Preferred - Rosette Highest Combined Score in Open B and Utility - Rosette Highest Scoring Junior Handler - Rosette Non-Regular Classes First Prize - - - - - - - - - - - - - - - - - - - - - - - - - - Rose Ribbon Second Prize - - - - - - - - - - - - - - - - - - - - - - - Brown Ribbon Third Prize - - - - - - - - - - - - - - - - - - - - - Light Green Ribbon Fourth Prize - - - - - - - - - - - - - - - - - - - - - - - - Gray Ribbon Highest Scoring Dog in the Regular Obedience Classes - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Blue & Yellow Rosette Highest Combined Score in Open B & Utility Classes - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Blue & Green Rosette Highest Combined Score in Advanced B and Excellent B - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Blue & Green Rosette Qualifying Score in All Regular & Optional Titling Classes - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Dark Green Ribbon Rally Awards & Prizes Highest Combined Score in Advanced B & Excellent B - Rosette Highest Scoring Junior Handler - Rosette Junior Handlers must complete the Junior Handler portion of their entry form to be eligible for Junior Awards. 3/4 Jump Height Divisions for Obedience Dog s Measured Height at Withers Height to be Jumped Less than 10 4 / 8 10 to less than 12 1/2 8 / 16 12 1/2 to less than 15 10 / 20 15 to less than 17 1/2 12 / 24 17 1/2 to less than 20 14 / 28 20 to less than 23 16 / 32 23 to less than 25 1/2 18 / 36 25 1/2 to less than 28 20 / 40 28 to less than 31 22 / 44 31 to less than 33 1/2 24 / 48 33 1/2 to less than 36 26 / 52 36 to less than 39 28 / 56 Refer to Appendix A of the Obedience Regulations for a complete list of Breeds approved to jump 3/4 of their Measured Jump Height
OFFICIAL ENTRY FORM SPRINGFIELD MO DOG TRAINING CLUB FRIDAY August 3, 2018 SATURDAY August 4, 2018 Entries CLOSE: July 18, 2018 SUNDAY August 5, 2018 EACH EVENT FIRST OBEDIENCE ENTRY $28. SECOND OBEDIENCE ENTRY $25. EACH EVENT FIRST RALLY ENTRY $28 SECOND RALLY ENTRY $25 JUNIORS EACH ENTRY $15 PAY TO: SMDTC MAIL TO: JUDITH WALKER - SMDTC, 2251 HWY TT, ST. CLAIR, MO 63077 ENCLOSE $ FOR ENTRY FEES. $ FOR CATALOG. IMPORTANT-Read Carefully Instructions on Reverse Side Before Filling Out. Numbers in the boxes indicate sections of the instructions Class (print class and check days entered) Jump Fri Sat Sun BREED VARIETY (1) SEX NAME OF JUNIOR HANDLER (see back if any) FULL NAME OF DOG AKC REG. NO. AKC LITTER NO. ILP/PAL NO. FOREIGN REG. NO. & COUNTRY BREEDER SIRE DAM ACTUAL OWNER(S) 4 OWNER S ADDRESS Enter number DATE OF BIRTH PLACE OF BIRTH (list country) Do not print the above in the catalog CITY STATE ZIP NAME OF OWNER S AGENT AT (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 event, and by any additional rules and regulations appearing in the premium list for this event, 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. I (we) agree to conduct myself (ourselves) in accordance with all such Rules and Regulations (including all provisions applying to discipline) and to abide by any decisions made in accord with them. SIGNATURE of owner or his agent authorized to make this entry TELEPHONE # ARE YOU A NEW EXHIBITOR? YES NO E-MAIL Address (An acknowledgement of entry may be sent to this e-mail address) AKC Rules, Regulations, Policies and Guidelines are available on the American Kennel Club website, 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 the 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 expenses (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 there from, 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 BY ARBITRATION 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 your are entering, i.e., Cocker Spaniel (solid color black, ASCOB, parti-color); Beagles (not exceeding 13 inches, 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 dog show 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 a show 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 show 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 made to AKC. (For complete rules, refer to Chapter 11, Section 3.) If this entry is for Junior Showmanship, please give the following information: JUNIOR SHOWMANSHIP JR. S DATE OF BIRTH AKC JUNIOR HANDLER NUMBER 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 and agent/handler for pay while continuing to compete in Junior Showmanship. ADDRESS CITY STATE ZIP+4 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? AEN999 (11/08) relevant to the information needed in that box (PLEASE PRINT).