International Champagne
Horse Registry

Prefix: ----- Ms. Mrs. Mr. Miss Dr. Rev.   First Name:             Last Name:              

Other Family Members to be included in membership:

: RENEWAL -- Please check this box if this is NOT for a NEW membership --- if this is a membership RENEWAL. 
Then, please type your membership number in this box.  It's on your membership card.

Farm name if desired:

Mailing Address :             City:            

State or Province:          Please choose one AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IN IL KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Alberta British Columbia Ontario Manitoba New Brunswick Newfoundland Quebec Saskatchewan Mexico Europe Other Zip/Postcode:               

Country:            

Your email address:            

Your web page (optional):

Your interest in Champagne color horses:          please choose one interested own one or more breeding for the color

Your method of payment:           please choose one owe nothing PayPal    

(Please DO NOT use this form if paying by check or money order.  Use THIS MAIL-IN FORM instead.)