Nashua D.O.G. - New Member Registration - 2/6/2012

Account Information

Required fields are marked with an asterisk (*)

	*E-Mail Address:
	*Password:
	*Verify Password:

Nashua D.O.G. Use Only
Vaccinations: ID:
Rules: License:
Verified By:

Owner Information

*First Name:

*Last Name:

*Address:

*City:

*State:

*Zip Code:

*Phone:

Vet Information

*Name:

*Address:

*City:

*State:

*Phone:

*Zip Code:

Are you interested in volunteering?

Dog Information

	*Name	*DOB	*Breed	*Gender	*Fixed	*Dog License#	*Rabies Exp.	*Distemper Exp.	*Color
1

Tip: Use mm/yyyy for all date formats (Date Of Birth, Rabies and Distemper Vaccination Expirations).

*1. Has your dog(s) ever bitten, attacked, or otherwise injured another dog or person?
*2. Are you a member of a household that is covered by either a homeowner's or renter's insurance policy?

Rules, Waiver, Assumption of Risk, and Agreement to Hold Harmless

In consideration of the privilege of use of a certain portion of the parcel of land owned by Prosit, LLC, located at 120 Northwest Boulevard, Nashua, New Hampshire, I agree to assume any and all risk of death or injury to myself, my minor child(ren), and my dog(s) and further expressly agree to indemnify and hold harmless Nashua DOG Owners Group, Inc., Bellavance Beverage Corporation, Prosit LLC, and the City of Nashua, together with any and all of their officers, directors, aldermen, agents, representatives, employees, affiliates, subsidiaries, successors and assignors of and from any claim, action or loss, including such death or injury. I agree to abide by all City of Nashua Dog Ordinances and all rules and regulations as set forth by the Nashua DOG Owners Group as may be amended from time to time. I agree that I have read all rules and understand them. In addition, I agree to submit any changes to the above information in writing to Nashua DOG within 30 days.

Nashua DOG Playgroup Rules Nashua NH, City Ordinance, Chapter 5, Article I

*I have read the waiver, rules and ordinances and agree to the conditions as stated.

I'm a new user

Signed:	Date:
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