Owner/Lessee____________________________________________________________________________________________________________

Address_________________________________________________________________________________________________________________

City__________________________________________State__________Zip________________Phone_________________________________

Servicing Stallion__________________________________________________________________________Reg.No._______________________

Owner/Lessee___________________________________________________________________________________________________________

Address___________________________________________________City______________________________State________ Zip___________

                            $60 Mare Nomination Fee Due MARCH 1, 2010
                               $120 Mare Nomination Fee Penalty Due MARCH 2 thru MAY 1, 2010
                                  $180 Mare Nomination Fee Penalty Due MAY 2, 2010 until the 2010 Weanling Futurity

The Oregon Paint Horse Breeders/Triple Crown Futurities will not be responsible for any accident that may occur to any exhibitor, equipment, or horses. Signing of this form waives any and all claims against the OPHB/TCF or the management of any of their sponsored futurities. In signing this form, the undersigned acknowledges that they have read and agree to abide by the rules and regulations of the OPHB/TCF.

Signature of Owner/Lessee___________________________________________________________________________Date__________________

Rec’d By____________________________________________________Amount___________Check#______________Date_______________