P.O. Box 670
Charles Town, WV 25414
Phone: 304-725-2276 Fax: 304-725-1060
Mare Owner Information (as reported to the Jockey Club):
Name:
First________________________ Last______________________________ Middle Initial____________
Telephone_________________________ Fax_______________________________________
Cell_______________________________ Email_____________________________________
Farm Name__________________________________________________________________________
Address_____________________________________________________________________________
City_________________________________ State___________ Zip____________________________
Mare Information:
Mare’s Name_________________________________ Year Foaled____________ Color____________
Sire’s Name__________________________________ Dam’s Name_____________________________
Dam’s Sire______________________________
Produce History:
Mare’s 2013 Status: Maiden_____ Barren_____ Not Bred_____ or Foaling______________________
If mare has foaled, please indicate color_____, sex_____, & date ________ 2013
Covering Stallion 2012__________________________________ Last Date Bred in 2012____________
Year Sex
Foaled (Circle One) Date Foaled Sire of Foal
2012 C F __________________ __________________________________
2011 C F __________________ __________________________________
2010 C F __________________ __________________________________
2013 Breeding Season Boarding Farm: ___________________________________________________
Contact Name_______________________________________________________________________
Telephone_________________________________ Cell_____________________________________
Signature______________________________________________ Date________________________
** Please note: All mares presented for breeding must be vaccinated 7-90 days before breeding for the Equine Herpes Virus type-1. A veterinarian statement to this effect must accompany the mare to the breeding shed.