New Zion Shilohs: Policy and Prices July 2007

Pinewood Lazarus Comforth Zion
Josh and Laz, circa 1996

New Zion Shilohs
Home of the Breed Founder

“Breeding Better Shepherds” since 1962
(Revised 07/07)

 Tina and Lisa Barber
11922 North Rd.
Fillmore, NY 14735
(585)-567-8040

www.newzionshilohs.org
MaShiloh@aol.com

ISSR Breeder #: LBZ090005 and NYS Kennel #: PD00373

Prices and Policies
 

Duster Bogey Down and Kari
Lisa with Kari and Boeg,
circa 1982


Building on a Solid Foundation!

A.     BREEDING and SALES POLICY: The goal of New Zion Shilohs is to produce the TOTAL dog, worthy enough to be called a Shiloh Shepherd. New Zion Shilohs breeds to produce giant size, outstanding “working” temperaments with (stable-confident) qualities for STM (Shiloh Training Method), SAR (Search and Rescue), TDI (Therapy Dog International), ADI (Assist Dog International), herding, obedience, agility, etc.

We continually strive for superior intelligence, great hips and correct conformation pursuant to the ISSR, Inc. Breed Standard. These goals cannot be accomplished without the cooperation of those who purchase puppies and dogs from New Zion Shilohs or any other  licensed ISSR Shiloh Shepherd™ breeder. Regardless of the breed, professional breeders carefully select only those buyers who are prepared and willing to participate in all of the requirements and activities that accompany owning a professionally bred dog.  

Those interested in purchasing a real Shiloh Shepherd that can be registered with the International Shiloh Shepherd Registry, Inc. (ISSR) must purchase from a Licensed Shiloh Shepherd Breeder. These Breeders have worked hard to earn the designation of Licensed Breeder and, in order to retain their Licensed Breeder status, must continuously be in compliance with ISSR standards and must maintain detailed records about the health and temperament of each puppy in each litter. Failure to meet ISSR, Inc. Licensed Breeder standards and requirements will place the breeder at risk for losing their Licensed Breeder standing. Consequently, those who chose to purchase their Shiloh Shepherd from a Licensed Breeder must understand and accept that payment for a puppy/dog is only the beginning of their obligation to their chosen Breeder.

Only by adhering to these requirements can the future of the Shiloh Shepherd breed be ensured. We take our responsibilities seriously, and we hope that you will too! 

B.  DEFINITIONS: As used in this document, the following definitions shall apply: 

1)  Buyer: The individual and/or individuals purchasing the puppy from New Zion Shilohs and whose signature(s) appear on all documents related to the purchase. The terms “buyer” and “owner” may be used interchangeably and refer both to the singular and plural. The contracts, guarantees, etc. are with the buyer and do not necessarily follow the puppy in the event the buyer transfers ownership to another individual. The buyer remains responsible for its contractual obligations to New Zion Shilohs

2)  Co-owner: The terms “co-owner,” “breeder” and “seller” may be used interchangeably. 

3)  Puppy: This term is used interchangeably with “dog” and refers to any canine purchased from the breeder. 

C.  ISSR, INC. REGISTRATION: Failure to perform the activities required by the breeder and the ISSR, Inc. voids any and all guarantees that may accompany a puppy/dog, and also will be considered a breach of contract and may subject the responsible party to damages as described elsewhere in this and other documents. The exact procedures will be provided in correspondence from New Zion Shilohs and may be subject to change from the process described in this section. Persons unwilling or unable to meet registration requirements need not purchase a puppy from New Zion Shilohs. Activities and costs related to the process as well as conditions as described below are the responsibility of the buyer. 

1)  When a pup is between three and five months old, New Zion Shilohs will mail Blue/Yellow ISSR, Inc. Papers to the buyer. The buyer must complete, then return the Blue/Yellow Papers to New Zion Shilohs along with two photos of the puppy and a check made out to the ISSR, Inc. (New Zion Shilohs will inform you of the correct amount of the check to the ISSR, Inc.) The amount specified in this document may be subject to change. The amount as of the date of this document is $25 US funds. The buyer must return the aforementioned material before the pup’s six-month birthday. New Zion Shilohs will ensure that all paperwork is in order and forward it to the ISSR, Inc. The buyer will receive the pup’s Temporary Papers (Pink) before the pup’s eight-month birthday. 

2) Around the pup’s 11-month birthday, the buyer is responsible for reading and following the instructions received in the TCCP package that accompanied his/her dogs pink (temporary) certificate and follow the procedures for obtaining the pup’s permanent registration papers (described in Section D. below). The package will include detailed instructions, if you have any questions be sure to contact us, or ask someone on the New Zion Shilohs forum. Once your pup reaches one year of age, you must make an appointment to have the pup’s hips X-rayed. The entire adult registration package, including photographs, must be completed and returned to New Zion Shilohs (along with a check for $25 payable to the ISSR) before the pup is 14 months old. New Zion Shilohs, in turn, will submit the buyer’s documentation to the ISSR, Inc. The buyer, in most cases, will receive the pup’s permanent papers by his 16-month birthday. Additional time may be required for OFA/Penn Hip certification. In the event that any delays are likely to occur, the buyer must apply for an extension with the ISSR, Inc. as per ISSR, Inc. rules http://www.shilohshepherds.info/issr.htm . 

3)  Approximate costs for the activities required to register a pup are provided below. Costs will vary based on the geographical area, individual veterinary fees, etc.

  • Registration Fees: $50.00; (this includes the initial "puppy" registration and the one-year upgrade to permanent papers that will include all individual data as well as a 4 generation pedigree.

  • Hip Certification: Can run anywhere from $200-$400 depending on the clinic/procedure selected.  OFA preliminary X-rays are generally less expensive than the intense Penn Hip evaluation.

  • Temperament Test, ATT, or CGC with gunfire certification fee can vary from $10-$25 depending upon the tester/location;         

  • Photographs: $10.00; (traditional silver halide prints or digital copies are accepted) and

  • Fees related to late registrations. Please be sure to read the ISSR rules and regulations. 

D.    PUPPY CATEGORIES and PRICES: Each litter is evaluated individually and priced according to quality. New Zion Shilohs takes into consideration the pedigree (i. e., number of Champions in the first 7 generations), production performance of both the sire and dam, previous progeny evaluation at maturity (LMX as well as individual), hip history, etc.  Puppies are evaluated and classified into one of the following categories. Pricing is commensurate with the evaluation and assigned category. 

1)  Pet Quality (B/W-N): Puppies with serious faults, such as: gun shyness, severe under bite, multiple minor faults, or a diagnosed/physical handicap,  are sold only with non-breeding (B/W-N) papers and must be spayed or neutered.

  •   B/W-N (from *all categories)                           $1,000

2)  Pet Quality (B/W-U): Puppies that have minor faults, as per  the breed standard, that could make the puppy UNSUITABLE for Breeding or Showing fall into this category of Pet Quality. Minor faults may consist of anything that the Breed Warden/breeder believes should not be passed on to future progeny. Such faults include, but are not are limited to, the following examples: slight over/under bite,  retained testicle(s), extremely heavy/lowset ears, long muzzles with inadequate stops, smaller size/fine bone, possible short-hook-gay tails, etc.  Each puppy is evaluated individually for faults, at the LER,  as per the Breed Standard. The puppy's fault(s) will be listed on the guarantee making the guarantee for this puppy exempt from the specified fault(s).  Pet Quality puppies considered to be “non-faulty” at the time of sale, but not critical to the genepool expansion program,   may also be sold as Black/White Upgradeable (B/W-U).  The B/W-U designation means that the puppy may have the potential to be upgraded to Orange papered status (see below) provided certain conditions have been met. These conditions are specified elsewhere.  Pet Quality produced out of a red/white NB 1, 2, 3 litters are priced accordingly (listed below).

  •  B/W-U (from ORA/GOLD categories)                $1,550 

3)  “New Blood” – Red/White:

3a) New Blood 1 (NB1): NB1 puppies are the first generation of out-crosses. These pups are extremely healthy and full of hybrid vigor! Although some may be a bit smaller in size, most will reach the minimum standard requirements, and possess EXCELLENT “working” (Sch, S&R, TD, etc.) aptitudes with strong hips. Pricing is as follows:

Top Pet Quality B/W-U Papered $900
Specially selected puppies, co-ownership only $1,500
Top show quality, co-ownership only $2,500 

Please call for expected availability or visit our upcoming litters page for regular updates.

3b)  New Blood 2 (NB2): NB2 puppies have all the qualities of a NB1, along with a strong size increase. NB2 puppies possess the best of both worlds with a low RC (relationship coefficient) that reduces the potential for health problems as well as increased size. ! Pricing is as follows:

Top Pet Quality B/W-U Papered $1,200
Specially selected puppies, co-ownership only $1,700
Top show quality, co-ownership only $2,700

3c)  New Blood 3 (NB3): NB3 puppies still possess the desirable low RC’s that reduce the potential for acquiring immune deficiencies without ANY potential for loss of size!! Pricing is as follows:

Top Pet Quality B/W-U Papered $1,500
Specially selected puppies, co-ownership only $2,000
Top show quality, co-ownership only $3,000

3d)  Double New Blood (DNB): DNB puppies are the ULTIMATE combination in that they will maintain healthy VIGOR, without excessive LOSS of size! They may also possess  strong LMX (Litter Mate X-Ray) data, with EXTREMELY STABLE temperaments and EXCELLENT working qualities! Pricing is as follows:

Top Pet Quality B/W-U Papered $1,800
Specially selected puppies, co-ownership only $2,500
Top show quality, co-ownership only $3,500

* Any puppy in the above categories deemed to possess serious faults  will be reduced to B/W-N category as per Section D, item 1.

All other puppies are priced as follows: 

4)  Orange (ORA): Non-champion bred 4th generation NB puppies are produced from the BEST QUALITY stock with the LARGEST POSSIBLE SIZE!! The offspring from such litters are judged individually and the best specimens are placed in Show/Breeding homes. They are fully guaranteed to be exceptional representatives of the Breed.  Males will EASILY reach the 30’’ plus size and females will range up to 28’’ and LARGER!! These future potential CHAMPIONS CAN BE FULLY GUARANTEED AGAINST ANY FAULTS THAT WOULD PREVENT THEM FROM BEING SHOWN! Even though breeding and showing is encouraged, it is not a mandatory requirement for owners of ORA papered pups. Best specimen puppies are ORA papered and only sold on co-ownership agreements/contracts. The price for ORA papered puppies is $2,250. 

5)  Gold (GOL): Gold papered puppies are from lines with 7 or more champions and/or puppies from our fourth generation NB lines that possess a Champion sire/dam and three or more titled Shiloh Champions (in their first three generations) and are considered to be the ULTIMATE QUALITY POSSIBLE!! These dogs have proven themselves in the registry as well as the show ring. They possess the strongest gene pool possible to produce the MOST awesome Shilohs, as close to perfection as can be attained!! Specially selected offspring from such breedings are fully guaranteed to be EXCELLENT SPECIMENS of the breed and should, themselves, be bred and shown. (Remaining littermates will be reduced to (ORA) breeding or Pet Quality only as previously described, furthermore these pups are guaranteed to meet all GOLD requirements and to qualify for all privileges associated with this category as per the ISSR rules.  Gold papered puppies are only sold on co-ownership agreements/contracts along with the extended show guarantee. The price for Gold papered puppies is $3,250. 

*Please note: Our pricing policies are based on the SSDCA, Inc. approved guidelines that are upheld by all ISSR, Inc. Licensed Breeders!

E.      UPGRADES:  In some circumstances and at the sole discretion of New Zion Shilohs, puppies sold as B/W-U may be upgraded provided all of the following conditions have been met BEFORE the dog’s permanent papers have been issued: 

1)   All required paperwork must be completed and submitted as per ISSR Rules

2)    A separate ISSR, Inc. application must be submitted; 

3)    The ISSR, Inc. application must be accompanied with written approval of both the breeder and co-breeder of the subject dog and the Breed Warden;  

4)    Owners must have contacted New Zion Shilohs to arrange for the additional payment of: the difference between the original category price paid and new category price; and 

5)    Full examination of the puppy by New Zion Shilohs.  

If an upgrade is approved by New Zion Shilohs, the buyer’s failure to upgrade a Black/White Upgradeable (B/W-U, refer to Section D. above) dog shall void any and all guarantees issued by New Zion Shilohs. Additionally, if financial losses are suffered by New Zion Shilohs as a result of the buyer’s failure to upgrade a B/W-U dog, the buyer shall be financially responsible for those losses.  

 

F.    GUARANTEES:  See applicable PET (B/W-N or B/W-U), RED (breeding or show), ORA or GOLD puppy guarantees.

G.  CO-OWNERSHIPS:   RED, ORA and GOLD papered dogs are sold only on Co-ownership contracts. Please refer to the applicable contract for information pertaining to co-ownership contracts. (Females: Co-Ownership Contract or Males: Breeders Agreement)  

H.    STUD SERVICE:  Please refer to the Stud Service Contract 

I.  RESERVATIONS, PAYMENTS and CHARGES:  Since the demand for New Zion Shilohs puppies is usually much greater than the supply, we strongly recommend that you reserve a puppy early! Litters are usually sold out 3-10 months prior to birth. Reservations, payments and other charges are described below: 

1)  Deposits and Prepayments:  To secure a specific “pick” puppy position for 10 business days, a $400 deposit is required. After that time, the pick position will automatically be “bumped” down the list as prepayments (full price) are received.

Example: If a buyer sends a deposit in January for a specific pup due to be born in May, the buyer will secure a pick puppy position for 10 Business Days commencing on the day
New Zion Shilohs receives the deposit. Failure to pay the balance by the end of the tenth business day may result in the loss of the “pick” puppy position. Such loss would occur if the balance is not paid before the end of the tenth business day and New Zion Shilohs receives a prepayment from another buyer. After this grace period expires, the first buyer’s puppy pick position will then be dropped to Second Pick, and so on.

Only prepayments will guarantee pick puppy position.

Pick puppy positions are also determined by the order in which prepayments are received.  

In the event that a buyer prepays for a puppy then chooses not to take it, but to wait for another litter, the buyer will maintain his/her pick position on the next litter provided that an identical pick position in the designated puppy category is available. New Zion Shilohs will continue to work with buyers until their requirements can be fulfilled.

Under no circumstances will deposits or prepayments be refunded. 

2)   Additional Charges:  The following additional charges shall apply:

2a) Shipping Charges: The prospective owner is responsible for all costs related to shipping. Costs start at $350 and include an FDA and airline approved shipping crate, Department of Agriculture Interstate Heath Certificate,  etc. The shipping charge must be prepaid and received by New Zion Shilohs at least ten days prior to the scheduled date of shipping. Shipping Procedures are discussed elsewhere in this document.

2b)  Puppies to be picked up in person may also receive an official Department of Agriculture Interstate Health Certificate as well as their Micro chip registration certificate, the new owner will be responsible for reimbursement of the $100 fee (to cover these costs) at the time of pickup. 

2c)   Failure to take possession of a puppy when the puppy is ready to leave New Zion Shilohs will result in the following charges:

  • A $75 Special Handling Charge;

  • A daily boarding charge of $10 per day that the pup remains at the kennel until possession is taken; and

  • The cost of all veterinarian/medical care and related costs, e. g., medications, plus 10% for kennel staff to administer treatment.  This includes standard scheduled vaccinations and wormings.

3)  Forfeiture of Deposit:  If New Zion Shilohs has a pup that meets the owner’s requirements and has held said puppy for the new owner until the time the new owner is scheduled to take possession, and the new owner then decides, for any reason whatsoever, that he/she prefers to wait for another litter, the new owner automatically will forfeit the $400 deposit. Any additional monies that have been paid will be credited toward the next litter.  Failure to pay the balance due on that puppy, prior to shipment or pickup will VOID the entire contract and no funds will be refunded.

New Zion Shilohs constantly strives to meet a prospective new owner’s exact requirements. With this interest as its priority, New Zion Shilohs may change a new owner over to another litter if it is believed that the new owner would be getting a higher quality pup. In many cases, New Zion Shilohs UPGRADES a new owner’s choice to a higher priced litter if the new owner has been on the books for a while and still has not received the exact puppy he/she wants.  The goal of New Zion Shilohs is to provide each new owner with a puppy that be can enjoyed for years to come!! If New Zion has chosen to provide a specific upgrade to a buyer, then NO additional funds will  be expected from the new future owner!  

4)  Method and Form of Payment:  Payments may be made in the form of money orders, cash or wire transfer. Personal checks are not accepted unless received by New Zion Shilohs no less than 30 days prior to the scheduled shipment or “pick up” date of the puppy. All payments, regardless of the payment form, received less than 10 days prior to the scheduled shipment or pick-up date are considered to be late payments. New Zion Shilohs needs adequate time to assure a proper health examination and micro chipping by a licensed veterinarian prior to releasing any puppy to their new owner. New York State Department of Agriculture health certificates are only valid for 10 days, if additional certificates have to be obtained for a specific puppy the owner will be responsible for the additional charge that could run as high as $140 for the special house call and certification. Handling of late payments is discussed in the next section. 

5)  Late Payments:  Late payments will delay the scheduled shipping or pick-up date of your puppy. The consequence of the delay is the Special Handling Fee of $75 discussed above in the section entitled “Additional Charges” plus $10 per day for each day the pup remains at New Zion Shilohs kennel beyond the scheduled shipping or pick-up date. NSF checks returned to New Zion Shilohs will be treated as “Non-Payment” for the said pup and will result in the forfeiture of any prior payments or deposits. In the event a prospective owner is unable to pay the balance due on a selected pup, the prospective owner may elect to either forfeit his/her deposit or make payments over time. Terms for “time payments” shall be arranged on an individual basis with New Zion Shilohs. New Zion Shilohs reserves the sole right to determine if the terms are acceptable.

Under no circumstances will any puppy be “held over” for more than four weeks. If the total balance plus all other charges remain unpaid at the end of four weeks  after the previously scheduled shipping or pick-up date, all funds paid on said puppy will be forfeited. Neither refunds nor credit slips will be provided or due. 

J.   SELECTIONS:   All puppy selections are based strictly on an order-of-payment system, i. e., the first prepayment on a particular litter, receives first pick puppy.  The second prepayment received gets second pick, etc. pursuant to the previous section, “Reservations, Payments and Charges.” The procedure for picking a puppy is as follows: 

1)  At 5-7 weeks of age, pictures are taken of the pups and sent to the prospective new owners, along with descriptions and recommendations as to personality (type of temperament), future color, size, etc. Any change in the original selection must be made at this time. Final confirmation must be provided immediately after the Litter Evaluation Report (LER) is completed. 

2)   In the event that a prospective owner is not satisfied with the sex, color, coat, etc. of the available pups from the originally selected litter, the prospective owner may choose to have his/her payment transferred to the next available litter in the same puppy quality category. While this decision often results in a longer waiting period, it also may result in a much better “selection” position. Such a transfer may be done only once and is at the sole discretion of New Zion Shilohs

3)    Prospective owners will be placed on an “automatic standby” status in the event a transaction is not completed on another puppy in the desired category. 

All pre-paid clients will be given access to the private New Zion Shilohs forum, and are encouraged to post questions/read updates/share stories, etc.

4)  Anyone that has submitted a puppy application with just a deposit will be placed in a folder that best represents his requirements, e.g., Male-Female, Smooth-Plush, and will be contacted in the event that there are any available puppies that meet their criteria, in a specific litter.  At this point the buyer can choose to accept that particular puppy by immediately sending in the balance plus shipping charges or make arrangements for pick up.

K. SHIPPING PROCEDURES:  Pups are shipped via PDQ (Priority Counter to Counter).  The specific Airline Company used to ship the pup will depend on scheduled flights to the prospective owner’s area.  All puppies are shipped between eight and nine weeks of age. Pups are shipped with complete “shots and worming” history along with a valid (within 10 days) health certificate and complete nutritional/feeding instructions. Prospective owners will be notified in advance of the approximate shipping date. All dates are subject to change in the event of harsh weather conditions. Prospective new owners will NOT be charged for such delays. 

L   REPEAT BUSINESS:  Repeat business always is appreciated. All repeat customers shall receive a 20% discount on ANY additional puppy purchased at the same time, even if future delivery is arranged. Any additional puppy purchase at a later date will still qualify for a 10% discount.

      This repeat business discount DOES NOT apply to adults, trained protection dogs, or dogs purchased on co-ownership or breeder’s agreement contracts

M.  GUARANTEED REPLACEMENTS and CREDIT SLIPS:  All New Zion Shilohs pups are sold with a guarantee applicable to the puppy’s papered category (see the section entitled “Puppy Categories and Prices). If, pursuant to the terms of the guarantee, it is determined that a replacement pup is due, then a credit slip will be issued. It is the policy of New Zion Shilohs to not make cash refunds. Owners strongly are encouraged to carefully read their puppy’s guarantee. If a replacement is due as the result of a genetic defect, all conditions of the guarantee must be met. Additional clarification is as follows: 

1)    No replacement will be made nor credit given to any owner who has his/her dog destroyed or makes the dog unavailable for autopsy by a veterinarian acceptable to and agreed upon by both New Zion Shilohs and the owner. No credits slips will be issued to anyone who cannot prove through sales receipts that the nutritional guidelines of New Zion Shilohs have been followed to the fullest. 

2)   If a credit slip is due, it will be issued for the original amount paid and only after the owner’s guarantee receipt is presented and verified by New Zion Shilohs records. 

3)    A credit slip may be applied towards the purchase of any available Shiloh pup or adult dog. In the event the owner chooses a dog that is more expensive than the one being replaced, the cash difference must be paid to New Zion Shilohs in accordance with the section entitled “Reservations, Payments and Charge.” 

4)    All deposits and credits slips will be carried on the books of New Zion Shilohs for a period of 180 days/6 months. If the owner chooses not to use his/her credit slip and/or refuses to pay the balance of the purchase price, if any, of the selected replacement pup/dog, then the owner shall be considered to have forfeited all claims. 

5)  In the event a replacement puppy is unavailable, New Zion Shilohs will extend the credit slip until such time as a puppy in the owner’s category is available. The extension also may be renewed every 180 days/6 months by written request of the owner. New Zion Shilohs reserves the right to refuse any further extensions if the owner who is due a replacement fails to accept a particular puppy that he/she has requested to be held. If arrangements cannot be made to ship the pup or the owner refuses to pick him/her up prior to 9 weeks of age, the owner will be responsible for any additional handling fees and charges (refer to the section entitled “Reservations, Payments and Charges” elsewhere in this document).  

6)  Guarantees are made by the breeder to the buyer. The buyer should not assume that any guarantee follows the dog in the event the buyer transfers ownership of the dog to another party.  

N.   MEMBERSHIPS:  Buyers and individuals interested in breeding dogs purchased from New Zion Shilohs are required to maintain organizational and/or program memberships as follows: 

1)       Shiloh Shepherd Dog Club of America (SSDCA):

  • Buyers of Pet Quality dogs are required to join the Shiloh Shepherd Dog Club of America (SSDCA) and maintain that membership for a minimum of one year.

  •  Buyers of ORA, RED or GOLD papered dogs are required to join the SSDCA and maintain that membership as long as the dog is active in the show ring or in a breeding program.

  • Buyers purchasing a dog on a co-ownership shall join the SSDCA and maintain that membership for the life of the co-ownership agreement. 

2)    Licensed Breeder (LB) program:  Buyers who also intend to become Shiloh Shepherd breeders are required to participate in and become an active member in the LB program. Only puppies bred by Licensed Breeders may be ISSR, Inc. registered. Additionally, New Zion Shilohs strongly encourages any Shiloh Shepherd owner intending to breed Shilohs Shepherds to register his/her kennel before attempting to register any puppies. 

Our interest in you does not end with a “Sale” - it only begins there! We want to do ALL that we can to help you bring your very special dog to his/her full potential! Special forum privileges, Newsletters, Seminars and Homecomings are provided for all Shiloh owners through the Shiloh Shepherd™ Dog Club of America, Inc.  Please plan to join us now and become an active member of the Shiloh Family!

My signature below certifies that I have received, read, understand and agree to the Policies and Prices of New Zion Shilohs as set forth in this document. Having read and accepted all terms and requirements set forth in this document, enclosed is my payment in the amount of $____________ as a deposit/prepayment for:

 

Male
 
Female
 
Plush
 
Smooth
 

 

Quality (check the appropriate box)

Show
 
Breeding
 
Pet Upgradeable
 
Pet Non-Upgradeable
 

Color:  ______________________  Temperament: ____________________

 

New Zion Shilohs reserves the right to substitute any litter of

equal/higher value that is compatible with your exact requirements.

 

Name: (Print) ____________________________________ Email address: ____________________

SSDCA Club Member:  Yes ___  No ___  If yes, as of: _________________
Number and Expiration Date:
_____________________
_

Address: _________________________________________ City: ____________________
Zip: ____________ Country: __
_________ Phone: _____________________

Signature: _____________________________________________________ Date:_____________

Additional Comments:

 

 

 

  Please sign and return the original and keep a copy for your records!

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