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 Sweetheart Classic  - page 4 / 4

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CERF EYE CLINIC

Saturday, February 13, 2010, at 11:00 AM

Dr. Nicholas Millichamp, BVetMed, PhD, DVOphthal, MRCVS

SCHEDULE: We will attempt to schedule you for a specific time, to hopefully avoid long waits!  When you receive email confirmation of your registrations, you will be asked for 1st and 2nd choices for times most convenient for you.  Your scheduled time will then be emailed to you.

PRE-REGISTRATION ONLY!  NO DAY OF CLINIC REGISTRATIONS WILL BE ACCEPTED!

Deadline for RECEIPT of pre-registrations is Monday, February 8, 2010!!

EASTEX ASC CLUB MEMBERS:  $25.00 per dog -- NON-CLUB MEMBERS:  $27.00 per dog

Make checks payable to “Eastex ASC” and mail to:

Leona Stabler, 7070 Rye Loop Rd., Bryan, TX  77807

979-822-5715 between 8 am & 3 pm-- leona@txsigns.org

PLEASE PRE-REGISTER WITH THE FORMS BELOW

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Owner:                                                                                                                                               

________________________________________________________________________________________________________________________

Address (street & no., city, state, zip)

________________________________________________________________________________________________________________________

Animal registered name                                                                                                            Breed/variety                                         Coat color/type

____________________________________________________________________ / ______________________________ / __________________

Registration No.                                   Sex               Date of Birth                  Tattoo/Microchip No.                    Email addy

_____________________________ / ______ / ________________ / _________________________ / _____________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ----------

Owner                                                                                                                                                

________________________________________________________________________________________________________________________

Address (street & no., city, state, zip)

________________________________________________________________________________________________________________________

Animal registered name                                                                                                          Breed/variety                                          Coat color/type

___________________________________________________________________ /______________________________  / ____________________

Registration No.                                     Sex             Date of Birth                 Tattoo/Microchip No.                      Email addy

_____________________________/_______/_________________/___________________________ / ____________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ---------

Owner:                                                                                                                                              

________________________________________________________________________________________________________________________

Address (street & no., city, state, zip)

_________________________________________________________________________________________________________________________

Animal registered name                                                                                                          Breed/variety                                       Coat color/type

________________________________________________________________ / ________________________________ / ______________________

Registration No.                                   Sex             Date of Birth                  Tattoo/Microchip No.                     Email addy

________________________________/________/___________________/______________________________ / ________________________________________

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