| Name | Sex | Year Born |
Sire | Dam | Division | Reg. No. |
| Owner: . |
SS#: | NCHA Membership No. |
| Address: . |
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| City, State, Zip: . |
Phone: | |
| Winnings made payable to: . |
SS#: | or Tax ID#: |
| Rider:
Riders NCHA# . |
||
| Correspondent: (If Different from owner) |
||
| Address: . |
||
| City, State, Zip: . |
Phone: | |
| Signed By: . |
NCHA Membership No. | |
(No Checks will be dispersed if SSN or Tax ID# for entry is not on file.)