Saturday and Sunday, March 14 & 15, 2015images.akc.org/.../2015/Premium_List.pdf · V3 ~ 1/14/2015...

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P REMIUM L IST V3 ~ 1/14/2015 2015277106 American Kennel Club’s 21 ST NATIONAL OBEDIENCE CHAMPIONSHIP Saturday and Sunday, March 14 & 15, 2015 1 st Round Invitations Closing Date – Friday, January 16, 2015 at 4:00 pm Eastern Time 2 nd Round Invitations Closing Date – Friday, February 6, 2015 at 4:00 pm Eastern Time PURINA EVENT CENTER 300 CHECKERBOARD DRIVE Gray Summit, MO 63039 JUDGES: Ms. Julianne Cepulis Mrs. Patricia Krause Mr. Donald A. Levinson Ms. Kathy Moore Mrs. Diane J. Propst Mr. Richard Strong Mr. James D. Thomson Ms. Teresa E. Walker CERTIFICATION Permission is granted by the American Kennel Club for the holding of this event under American Kennel Club rules and regulations. James P. Crowley, Secretary 1

Transcript of Saturday and Sunday, March 14 & 15, 2015images.akc.org/.../2015/Premium_List.pdf · V3 ~ 1/14/2015...

Page 1: Saturday and Sunday, March 14 & 15, 2015images.akc.org/.../2015/Premium_List.pdf · V3 ~ 1/14/2015 2015277106. American Kennel Club’s . 21ST NATIONAL OBEDIENCE CHAMPIONSHIP. Saturday

P R E M I U M L I S T V3 ~ 1/14/2015 2015277106

American Kennel Club’s

21ST NATIONAL OBEDIENCE CHAMPIONSHIP

Saturday and Sunday, March 14 & 15, 2015

1st Round Invitations Closing Date – Friday, January 16, 2015 at 4:00 pm Eastern Time 2nd Round Invitations Closing Date – Friday, February 6, 2015 at 4:00 pm Eastern Time

PURINA EVENT CENTER 300 CHECKERBOARD DRIVE Gray Summit, MO 63039

JUDGES:

Ms. Julianne Cepulis Mrs. Patricia Krause Mr. Donald A. Levinson Ms. Kathy Moore Mrs. Diane J. Propst Mr. Richard Strong Mr. James D. Thomson Ms. Teresa E. Walker

CERTIFICATION Permission is granted by the American Kennel Club for the holding of this event under American Kennel Club rules and regulations.

James P. Crowley, Secretary

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OFFICERS OF THE AMERICAN KENNEL CLUB

President & CEO, Dennis B. Sprung 260 Madison Ave., New York, NY 10016-2408 Exec. Secretary, James P. Crowley 260 Madison Ave., New York, NY 10016-2408 Chief Financial Officer, Peter W. Farnsworth 260 Madison Ave., New York, NY 10016-2408

BOARD OF DIRECTORS Alan Kalter, Chairman

Dr. J. Charles Garvin, Vice Chairman Class of 2015: Robert A. Amen, Dr. Carmen L. Battaglia, Steven D. Gladstone, Esq. Class of 2016: Patricia M. Cruz, William J. Feeney, Thomas S. Powers, Esq. Class of 2017: Lee Arnold, Carl C. Ashby III, Alan Kalter, Harvey M. Wooding Class of 2018: James R. Dok, Dr. J. Charles Garvin, Ronald H. Menaker Dennis B. Sprung, Ex Officio

AKC NATIONAL OBEDIENCE CHAMPIONSHIP EVENT COMMITTEE

Event Chair Pamela Manaton, 8051 Arco Corporate Drive, Suite 100, Raleigh, NC 27617-3390 Event Co-Chair Diane Schultz, 8051 Arco Corporate Drive, Suite 100, Raleigh, NC 27617-3390 Trial Secretary Lisa Strickland, 8051 Arco Corporate Drive, Suite 100, Raleigh, NC 27617-3390

Doug Ljungren, Vice President, Sports & Events

Executive Staff Field Representatives: Bill Thayne, Mary Higdem and Sharon Hodgens-Wood

EVENT VOLUNTEERS/SUPPORT

Chief Volunteer Coordinator

Sandy Ganz Ring Commentary

Ken and Aimee Kincaid

Hospitality Paula Spector

Sr. Tabulator Nancy Watson

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AKC NATIONAL OBEDIENCE CHAMPIONSHIP JUDGES

Ms.Julianne Cepulis (0331) 3163 N. 94th Street

Milwaukee, WI 53222-3516

Mrs. Patricia Krause (2906) 4329 Islandview Rd.

Rhinelander, WI 54501-8281

Mr. Donald A. Levinson (4454) 51 Cockrell Street

Alexandria, VA 22304-6302

Ms. Kathy Moore (26196) 12225 Willow Drive

Norco, CA 92860-2765

Mrs. Diane J. Propst (1791) 2674 Wilson Bend Road

Gravois Mills, MO 65037-6728

Mr. Richard Strong (2197) 7721 Cardinal CV N

Indianapolis, IN 46256-4634

Mr. James D. Thomson (2720) 78933 Falsetto Drive

Palm Desert, CA 92211-4015

Ms. Teresa E. Walker (39266) 499 Sergeantsville Road

Flemington, NJ 08822-2712

PHOTOGRAPHER

Pix ‘N Pages PO Box 690733

Orlando, FL 32869 Phone: (407) 536-PAWS (7297) Email: [email protected] Website: www.pixnpages.com

PUBLICATION RIGHTS – PHOTOGRAPHS & VIDEOS By entering this show, all owners, handlers, breeders and kennels agree that all rights to televise, videotape, photograph, advertise, promote and publicize or otherwise exploit this show, or the persons or animals participating in it or the results of the competition before, during or after the event, shall belong solely to The American Kennel Club and their respective assigns, including the use of the names, likenesses or biographical matter of all dogs, owners, handlers, breeders and kennels participating in the show and no such owner, handler, breeder or kennel shall allow any other party to make commercial use of any videotape or photograph of any person or animal participating in this competition. NOTE: By entering this show all owners, handlers, breeders and kennels agree to make themselves available for interview if requested. Exhibitors may video tape individual runs only for personal use.

Win pictures will take place at the Official Photo set up immediately after the Awards Ceremony All winners are ASKED TO STAY FOR THEIR OFFICIAL WIN photos!!

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AKC NATIONAL OBEDIENCE CHAMPIONSHIP FORMAT SATURDAY’S COMPETITION:

• There will be eight rings and the teams will perform two to three exercises in each of the eight rings. The exercises will be a mix of the regular class open and utility exercises.

• Approximately 20 teams will be assigned to start in each ring. Your starting ring and armband numbers will be sent to you approximately three weeks prior to the event.

• Teams starting in Ring 1 will proceed to Ring 2 in catalog order. Teams starting in Ring 2 will proceed to Ring 3; Teams starting in Ring 3 will proceed to Ring 4 and so on.

• There will be a set of Open Group Exercises on Saturday. All dogs will be assigned a ring number to report to for Groups. Your Group Exercise Ring information, Starting Ring number and Armband number will be sent to you approximately three weeks prior to the event.

• Judging will stop at approximately 11:30 a.m. on Saturday so that all rings can prepare to do the Group Exercise at the same time.

• A lunch break for all rings will be taken after the Group Exercise.

• Afternoon judging will resume approximately one hour after the completion of the Group Exercise.

• At the conclusion of Saturday’s competition, if necessary, runoffs will be conducted to determine the “Top 50” dog and handler teams, as well as the top four Group Placements.

• Once the runoff results are tabulated the “Top 50” teams will be announced. These are the teams that will move on to compete on Sunday for the final top awards.

• An Awards Ceremony will take place at the conclusion of Saturday’s event to award the top four Group Placement winners of the 2015 National Obedience Championship.

SUNDAY’S COMPETITION:

• Sunday morning the “Top 50” handler/dog teams will perform two exercises in each of the eight rings similar to the Saturday format.

• At the completion of the “Top 50” competition, the “Top 20” handler/dog teams will be determined by cumulative score.

• The “Top 20” will then perform a series of exercises to determine the “Top 10” handler/dog teams.

• The “Top 10” handler/dog teams will be ranked by cumulative score.

• An Award Ceremony will be held at the conclusion of Sunday’s event where the “Top 10” teams of the 2015 NOC will be announced!

The Scent Discrimination Exercise may be performed up to four different times over the course of the competition. Please be certain to bring a sufficient number of articles with you as articles may not be reused.

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ENTRY ELIGIBILITY & INFORMATION This event is by invitation only. To be invited to participate, each dog must be ranked in the top 25 dogs by OTCH points or ranked in the top 3 of its breed by OTCH points. If there are more than thirty (30) dogs that qualify in a specific breed, then we will take a ratio of the total and invite that amount. In addition, the top 4 dogs from each of the Obedience Regional Events will be invited based on the qualification criteria as written in the AKC Obedience Regulations, Chapter 16, Section 2, AKC Regional Competitions. Dogs must meet the minimum entry requirements in order to participate at this event and must also meet the eligibility requirements specified in the AKC Obedience Regulations. Qualifying Period for the event is December 1, 2013 – November 30, 2014 1st Round Invitations will be mailed no later than December 22, 2014. In the event that it is necessary to send out a 2nd Round of Invitations they will be mailed no later than Tuesday, January 20, 2015. 1st Round Closing Date for entries will be Friday, January 16, 2015 at 4:00 pm Eastern Time 2nd Round Closing Date for entries will be Friday, February 6, 2015 at 4:00 pm Eastern Time National Obedience Championship Entry Fee $ 140.00

ENTRIES NOT ON THE OFFICIAL AKC NATIONAL OBEDIENCE CHAMPIONSHIP ENTRY FORM OR PHOTOCOPIES OF THE ENTRY FORM without the Agreement and rules on the reverse side are NOT ACCEPTABLE. No entry shall be made or accepted, which specifies any conditions as to its acceptance. Mail entry form and fees to: American Kennel Club, Attn: Companion Events - NOC Entry Form, 8051 Arco Corporate Drive, Suite 100, Raleigh, NC 27617-3390. Please make checks payable to: AKC National Obedience Championship. No entries will be accepted by hand delivery or by phone. Express mail & overnight entries must include the signature waiver allowing them to deliver the package. Illegible entries will not be processed and will be returned to the exhibitor. Returned checks do not constitute a valid entry. A twenty-five ($25.00) dollar collection fee will be added to the amount of each returned check. ERRORS ON ENTRY FORMS Owners are responsible for errors on entry forms and no entry fee will be refunded in the event of such errors or cancellation of entries after the trial has closed. Confirmation of Entry. You will receive a confirmation email that your entry has been received and accepted. If you do not receive your email within two weeks of mailing please notify us at [email protected]. Please be sure to provide a valid email address. If you have questions concerning the National Obedience Championship please email us at: [email protected].

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HOTEL INFORMATION Exhibitors and attendees will receive a special rate when they ask for the “AKC” or “American Kennel Club” Group Rate at these hotels in the Gray Summit, MO area. You will be asked to sign a pet damage waiver upon check-in. NOTE: Your credit card will be charged a one-night room and tax deposit when you book your reservation.

1. Holiday Inn Six Flags – Headquarter Hotel (approx.. 10 miles to Purina Farms) 4901 Six Flags Road Eureka, MO 63025 Hotel Direct: (636) 938-6661 Toll Free Reservations: 1-800-782-8108 Room Rate is $109 per night plus taxes $20 one-time non-refundable pet fee

2. Travelodge (approx.. 2 miles from Purina Farms) 2875 US Highway 100 I-44 at Exit 253 Gray Summit Villa Ridge, MO 63089 Hotel Direct: (636) 742-3501 Toll Free Reservations: 1-800-782-8487 Room Rate is $79 per night plus taxes $15 one-time non-refundable pet fee

NOTE: These room blocks will be held until Tuesday, February 10, 2015 or whenever the block is sold out, whichever comes first. If you need assistance with reservations, contact Paula Spector, AKC Conference and Travel Director at (212) 696-8389 or by email at [email protected]

VOLUNTEERS NEEDED!!!

If you, would like to volunteer to work in the rings at this year’s AKC National Obedience Championship/AKC Rally® National Championship, please complete the form found under Volunteers on the AKC website at the link below, which are due by January 29th. http://www.akc.org/events/obedience/national_obedience_championship/index.cfm

RV PARKING RESERVATIONS All RV reservations for the NOC/RNC will be handled through AKC and the RV Reservation form will be available online Mid-January 2015. To be parked beside someone in your group, reservations should be submitted together.

RV & TRAILER RENTALS Attending the shows and don’t want to stay in a hotel? You have the option of renting a trailer or RV! The following companies will deliver it to the property and pick it up after the event. Contact the companies below for rental information. Exhibitors must make an RV Parking Reservation through AKC to park at the event.

• Byerly RV ~ Eureka, MO 636-938-2000

• M.B. Thomas RV ~ St. Louis, MO 800-392-5655

• St. Louis RV & Bus ~ O’Fallon, MO 314-743-3939

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DIRECTIONS TO THE SHOW SITE

http://www.purinafarms.com/directions-and-hours

IMPORTANT DEADLINE DATES TO REMEMBER!

January 15, 2015 o RV Parking Reservations Open

January 16, 2015 o 1st Round Entry Closing at 4:00 pm Eastern Time o 1st Round refund requests for cancelled entries deadline

January 20, 2015 o 2nd Round Entries will be mailed

January 29, 2015 o Volunteer Request forms due

February 6, 2015 o Catalog & Well Wishes Ads due o 2nd Round Entry Closing at 4:00 pm Eastern Time o 2nd Round refund requests for cancelled entries deadline o Award Donations due o Title updates are due

February 27, 2015 o RV Parking Reservations Close

March 14, 2015 o Refund request for bitches in season due 30 minutes prior to the start of the event

SUPPORT THE SPORT BY DONATING AN AWARD!!

We welcome your support! If you would like to sponsor an award for the AKC National Obedience Championship or the AKC Rally® National Championship visit the webpage below. The complete list of awards and prizes may be found at http://www.akc.org/events/obedience/national_obedience_championship/index.cfm. All award sponsors will be published on the AKC website. All donations received prior to Friday, February 6, 2015 will be published in the commemorative AKC National Obedience Championship / AKC Rally® National Championship catalog.

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ROSETTES, AWARDS & PRIZES Saturday Awards

• Top In Group Awards The top 4 Dogs from each Group will be awarded the following at the conclusion of Saturday’s competition. (Sporting, Hound, Working, Terrier, Toy, Non-Sporting, Herding, Misc./FSS/All American.)

1st Place 2nd – 4th Place

Engraved Plaque Engraved Plaque

Rosette Rosette

Purina Pro Plan Umbrella offered by Purina Purina Pro Plan Truck Organizer • Top 50

o Commemorative Top 50 Lapel Pin

o Purina Pro Plan Towel offered by Purina

Sunday Awards

• Top 20

o Rosette

• 2015 AKC National Obedience Champion

o $1,000 Cash Award*

o Soaring Eagle Crystal Trophy & Commemorative Wooden Box

o Rosette o Medallion

o Purina Pro Plan Best In Show Grooming Bag offered by Purina

• 1st Runner-Up

o $500 Cash Award*

o Commemorative Wooden Box

o Rosette o Medallion

o Purina Pro Plan Duffle Bag offered by Purina

• 2nd Runner-Up

o $200 Cash Award*

o Commemorative Wooden Box

o Rosette o Medallion

o Purina Pro Plan Duffle Bag offered by Purina

• 3rd Runner-Up

o $100 Cash Award*

o Commemorative Wooden Box

o Rosette

o Medallion

o Purina Pro Plan Duffle Bag offered by Purina

• 5th – 10th o Engraved Plaque

o Rosette

o Purina Pro Plan Duffle Bag offered by Purina

• 11th – 20th

o Purina Pro Plan Fleece Blanket offered by Purina

• 21st – 50th o Purina Pro Plan Grooming Towel offered by Purina

A participation certificate will be enclosed in the check-in packet for each dog. *All monetary awards will be mailed approximately 30 days after the competition. Winners of these awards must complete the award form and provide their Social Security Number to the AKC to receive the awards. Forms will be available at the event. All Purina prizes, if not awarded in the ring, must be picked up during the event at the Pro Plan Booth. Presentation of the Winning Ribbon is required. Pro Plan reserves the right to make prize substitutions of equal or greater value in the event a specific listed prize is not available.

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NOTICES TO ALL EXHIBITORS

TITLE UPDATES Title updates will be accepted until February 6, 2015. Please send any updates to [email protected]. ENTRY FEES Shall not be refunded in the event that a dog is absent, disqualified, excused by Veterinarian or Judge, or barred from competition by action of the Event Committee. If because of riots, civil disturbances or other acts beyond the control of the management it is impossible to open or to complete the trial, no refund of entry fees will be made. CANCELLATION OF ENTRY Requests to cancel an entry from the 1st Round will be allowed up until the 1st closing date which is Friday, January 16, 2015, at 4:00 pm Eastern time. 2nd Round entry cancellantions will be allowed up until the 2nd closing date which is Friday, February 6, 2015, at 4:00 pm Eastern Time. You may cancel your entry via email to [email protected] or by fax at 919-816-4204. Refunds for cancellations will be made within 45 days after the closing date for the event. REFUNDS FOR BITCHES IN SEASON To receive a refund for bitches in season a written veterinary statement must be provided to the Trial Secretary by Saturday, March 14, 2015, 30 minutes prior to the start of the first class in the trial. After March 14, 2015, entry fees will not be refunded for bitches in season. CRATING: Each dog entered in the AKC National Obedience Championship will be allotted one 3’x5’ space. Un-entered dogs will only be allowed in the facility if they can share the crate with an entered dog, or if their crate can be stacked on top of an entered dog’s crate within the 3’ x 5’ space.

A “crate” is defined as having a top, bottom and 4 walls, all interconnecting, thus preventing the dog from escaping. No ex-pens will be allowed in the facility. Each exhibitor will be required to display an information card on the outside of each crate; card(s) will be supplied at check-in. The information card must have your name and emergency contact information (cell phone # or other). EXHIBITOR CHECK-IN: Exhibitors are encouraged to do “Event Check-In” on Friday, March 13th. If you cannot check-in on Friday, exhibitors must do “Event Check-In” no later than 30 minutes prior to the start of the event. At Event Check-In, exhibitors will receive their armband, catalog and an event souvenir bag. The time and location for check-in will be sent via an email notification approximately two weeks prior to the event. Exhibitors MUST check-in at each ring, each day. FACILITY ACCESS: Exhibitors should unload their crates and enter the Purina Event Center through the large overhead roll-up door. Dog bathing facilities are available in the Event Center. No swimming (dogs and people) allowed in any pond on the property. All exhibitors and their dogs must remain on the part of the property owned by Purina Farms. Trespassing on Purina Animal Nutrition property is forbidden. Purina Farms and Purina Animal Nutrition are not affiliated. ALL DOGS MUST BE ON LEASH: Dogs must be on leash held by the handler at all times while on the event grounds except when in the ring or when in the designated obedience warm-up area. Dogs may NOT be on retractable leads or long-lines while inside the building. SPECIAL TRAINING COLLARS ARE PROHIBITED. WARM-UP RING: In accordance with the AKC Obedience Regulations, Chapter 1, Section 33 a warm-up ring will be available ONLY on Saturday & Sunday and ONLY for dogs entered in the AKC National Obedience Championship. No exhibitor is allowed to use the ring without AKC Staff in the building. Exhibitors are expected to share the ring. Individual ring time will not exceed 5 minutes. The ring will be monitored and if there are any problems, it will be closed. Exhibitors must be respectful of each other.

A Full Service Food Concession is available on site. No outside food or beverage is allowed on the Purina Farms Property. Violators will be reported to the AKC. No dogs are allowed in the Checkerboard Café, or on the second floor of the Purina Event Center (unless given prior permission) or in any restrooms or human bathing areas.

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NOTICES TO ALL EXHIBITORS CONT’D Parking No driving or parking is allowed in the following areas:

• Fire lanes, sidewalks, inside either Hall or any grass areas at Purina Farms. • All exhibitors must abide by all posted signage and the 15-minute unloading/loading parking

time limit designated around the Purina Event Center.

INCLEMENT WEATHER in the event a severe weather or tornado warning is issued for the immediate area, Site Security will notify the Purina Farms management team. The team will notify guests, participants and exhibitors of an impending weather event via the public address system inside the building and via the storm siren and announcements outside the building. Guests, visitors and exhibitors will be asked to seek cover in place in designated areas. Designated areas to seek cover, marked as severe weather shelter areas, include the center hallway of the Purina Event Center, the inside wall of Gateway Hall and the South stairwell. After the weather event ends, Purina Farms management teams will announce all clear. MOTORIZE VEHICLES exhibitors may not bring or use motorized vehicles on the property unless a medical condition requires the use of one. Documentation must be presented upon request by Purina Farms staff. SAFETY, BEHAVIOR and LIABILITY: The safety of the dog is our primary concern. By entering this trial, exhibitors acknowledge that they are familiar with the rules and regulations of the AKC. 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 an unnecessary disturbance or repeatedly engage in unsafe or disruptive behavior, may, at the discretion of the Event Committee, be asked to leave the show site. In such case, no refund of any fees paid will be made. The American Kennel Club and its agents, employees, etc., will assume no responsibilities for any loss, damage or injury sustained by exhibitors or handlers, or to any of their dogs or property and further assumes no responsibility for injury to children. The American Kennel Club reserves the right to decline entries for cause and may remove any dog on account of aggression. No one shall have any recourse or claim against the American Kennel Club or any official thereof. All dogs must be on leash, which must be held by the handler at all times when on trial grounds except when in the designated warm-up area or competing in the ring.

This club does agree to arbitrate claims as set forth on the Official AKC Entry Form for this event.

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HUMAN EMERGENCY SERVICES

FIRE / AMBULANCE / POLICE ~ DIAL 911 EMT SERVICES ON-SITE

St. John’s Mercy Hospital

901 East Fifth Street Washington, MO 63090

(636) 239-8000

Directions to the Hospital: • Start out going northeast on Checkerboard Dr. toward Operations Dr. • Right onto Highway MM / MO-MM, • Right onto Highway 100 / MO-100. • Merge onto I-44 W / US-50 W toward St. Clair. • Take exit 251 toward MO-100 W / Washington, turn slight right onto Highway. • Stay straight to go onto Highway 100 / MO-100, • Right onto E 5th St., hospital is on the right.

VETERINARIAN INFORMATION

Pacific Animal Hospital On Call 24 hours a day

450 W. Flier Drive Pacific, MO 63069

(636) 257-2100

Directions to the Animal Hospital: • Start out going northeast on Checkerboard Dr. toward Operations Dr., • Right onto Highway MM / MO-MM. • Right onto Highway 100 / MO-100, • Left onto W Osage St., • Right onto W Flier Dr. Animal Hospital is on the right.

Exhibitors should follow their veterinarian’s recommendation to assure their dogs are free of internal and external parasites, any communicable disease and have appropriate vaccinations.

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CATALOG & WELL WISHER ADS

CATALOG ADVERTISEMENTS

Advertisements in the 2015 AKC National Obedience Championship/ AKC Rally® National Championship catalog are WELCOMED! This year's exhibitor's catalog will be 8.5 X 5.5 inches, allowing a full-page ad area approximately 4.5 X 7.5 inches to post your message and/or picture. Camera ready ads are accepted in high-resolution press quality PDFs (preferred). JPEG or TIFF files are also acceptable (minimum 300 pixels/inch). If you are sending photos separately, the photos should be scanned to a finished size and at a minimum of 300 pixels/inch. Do not forget to include the correct orientation. Full page ads MUST be in a portrait orientation, and half page ads MUST be in a landscape orientation. If mailing, please send only high quality photos for scanning purposes.

Photos will be in black and white. Full page ad up to 4.5” X 7.5”……. $ 80.00 1/2 page ad up to 4.5” X 3.5”…… $ 55.00

WELL WISHERS

Send brief good luck wishes from you and/or your club. For $25.00 you can advertise to wish whoever “Good Luck” at the event. The catalog width will be 4.5 inches. The statement must be 25 words or less.

PAYMENT

You may pay by check, money order or credit card. By submitting a photo and payment for a space, you ensure that you are the author and copyright holder of the photograph.

Lisa Strickland ~ Trial Secretary AMERICAN KENNEL CLUB

8051 Arco Corporate Drive, Suite 100 Raleigh, NC 27617-3390

919-816-3816 [email protected]

ATTN: NOC CATALOG

Deadline for submission is Friday, February 6, 2015

Make checks payable to: AKC National Obedience Championship

IF PAYING BY CREDIT CARD, COMPLETE THE FOLLOWING: [ ] M/C [ ] VISA [ ] AMEX [ ] DISCOVER Total $

PLEASE PRINT CLEARLY

Name as it appears on Card: PLEASE PRINT

Card Number:

Exp. Date: Signature of Cardholder:

Address:

City, State, Zip Code

Phone Number:

Email Address:

(You will receive a confirmation email confirming your order at this address, so please be sure it is one that you check regularly.)

You may fax this order form to: (919) 816-4204 Attn: Lisa Strickland

(Fax orders are for Credit Card Payments ONLY.) 12