Riding Pony Stud Book Society
WA Branch
ABN: 52 082 005 187
"Futurity Stakes No. 13 2nd Nomination Form"
To be Judged 2015
'Yearling'
Second Nominations Due 31st July 2014
Fee: $27.00 per nomination (Entry Fee included)
1:
Name of Pony: ___________________________________ Reg No: _____________________
Date of Birth: ________________
Sex: ______________
Sire: _________________________________ Dam: _________________________________
2:
Name of Pony: ___________________________________ Reg No: _____________________
Date of Birth: ________________
Sex: ______________
Sire: _________________________________ Dam: _________________________________
3:
Name of Pony: ___________________________________ Reg No: _____________________
Date of Birth: ________________
Sex: ______________
Sire: _________________________________ Dam: _________________________________
Owners Name: ___________________________
Amount Enclosed: _____________________
Address: _________________________________
Phone Number: ____________________________
Member No: _________
Please make cheques/Money Orders in the name of: Riding Pony Stud Book Society WA Branch
RPSBSWA Bank Account Details for Direct Deposit BSB- 633 000 Account No:-133219279
Please address any enquires or entries to: Mrs Sandy Jamieson
726 Westcott Road
Keysbrook 6126 WA
0409722010
Please retain a copy for your own records.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Office Use Only
Date Received: ______________ Paid: ____________ Cash/Cheque/Money Order
Receipt Number: __________________________ Reference Number: ______________________