USASA Record of Merit Application Form
AKC Registered Name of Dog
AKC Registration Number
Submitted by
Date Submitted
Name of Registered Owner(s)
Are owner(s) current members of
USASA?
Address
Phone
City, State, ZIP
E-mail
Check certificate requested: (Please fill in C, P, or O for ROM titles)
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ROM-__ I Sire
 ROMX I Sire
ROM-__ II Sire
 ROMX II Sire
ROM-__ III Sire
 ROMX III Sire
Hall of Fame Excellent Sire
ROM- __ I Dam
 ROMX I Dam
 ROM- __ II Dam
 ROMX II Dam
 ROM- __ III Dam
 ROMX III Dam
 Hall of Fame Excellent Dam
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Tracking
Performance
Herding
Agility
Rally
Titles
Obedience
Obedience
Registered Name of Progeny
Conformation
PROGENY INFORMATION (Page 1)
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Send this completed form and the AKC progeny report as listed in the rules to:
Kathrin Phillips-Ellis
7007 Santa Fe Drive
Lubbock, TX 79407
Questions can be directed to:
raindayaussies@aol.com
Tracking
Performance
Herding
Agility
Rally
Titles
Obedience
Obedience
Registered Name of Progeny
Conformation
PROGENY INFORMATION (Page 2)