Duplicate Certificate - Aqha

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Duplicate Certificate
FOR OVERNIGHT DELIVERY TO AQHA: 1600 QUARTER HORSE DR, AMARILLO, TX 79104 • MAILING ADDRESS: P.O. BOX 200, AMARILLO, TX 79168
806 - 376-4811 •
806 - 349-6405
806 - 373-2281
Español
FAX:
INSTRUCTIONS: Please read carefully. A delay in processing will result if information is omitted.
• Part I must be completed by owner on AQHA records.
• Four full-view color photographs (front, back and both sides)
• AQHA retains the right to require additional information
are required in all instances. Not returnable.
and/or photographs before issuing a duplicate certificate.
• Part II completed if lost by someone other than owner
on AQHA’s records.
• Diagram on back must be completed.
• If a change in ownership needs to be made, please include
properly completed transfer report with appropriate fees.
PLEASE REGARD THIS AS A REQUEST FOR ISSUANCE OF A DUPLICATE CERTIFICATE FOR:
HORSE’S NAME
REGISTRATION NUMBER
PART
lI
To be completed in ALL INSTANCES by record owner
________________________________________________________________ ,
I,
hereby affirm that the sentence marked below describes the circumstances surrounding the loss or destruction of the
certificate for the horse identified above.
ONE OF THE CIRCLES BELOW MUST BE FILLED IN.
O
I lost the certificate.
O
I never received the certificate from AQHA.
O
_____________________________________________________________________________________________________
I mailed or delivered the certificate to:
NAME
ADDRESS
____________________________________________________________________________________
If given to an auction company, please also list the date of the sale
O
________________________________________________________________________________________________________________
Other (please explain):
The undersigned agrees to indemnify and hold harmless AQHA from any and all liability, whenever or however arising, by virtue of its reliance on this statement and its issuance of the replacement certificate; agrees to defend AQHA at his
expense; and if judgement is made against AQHA, to pay judgement and obtain written release in form acceptable to AQHA. Through the payment of a membership fee to AQHA, I acknowledge that membership in AQHA is voluntary and agree
to be bound by all the terms and conditions of AQHA’s Official Handbook of Rules and Regulations.
_____________________________________________________________________________________________
SIGNATURE OF RECORD OWNER
_____________________________________________________________________________________________________________________________________
ADDRESS
CITY
STATE/PROVINCE
ZIP CODE
_____________________________________________________________________________________________________
E-MAIL ADDRESS
OWNER’S DAYTIME TELEPHONE NUMBER
AQHA ID NUMBER
PART
lII
To be completed IN ADDITION to Part I if the certificate was not lost by record owner
I,
________________________________________________________________ ,
hereby affirm that the sentence marked below describes the circumstances surrounding the loss or destruction of the
certificate for the horse identified above.
ONE OF THE CIRCLES BELOW MUST BE FILLED IN FOR US TO PROCEED.
O
I received the certificate and lost it.
O
I never received the certificate from AQHA.
O
I mailed or delivered the certificate to AQHA.
O
_____________________________________________________________________________________________________
I mailed or delivered the certificate to:
NAME
ADDRESS
____________________________________________________________________________________
If given to an auction company, please also list the date of the sale
O
________________________________________________________________________________________________________________
Other (please explain):
The undersigned agrees to indemnify and hold harmless AQHA from any and all liability, whenever or however arising, by virtue of its reliance on this statement and its issuance of the replacement certificate; agrees to defend AQHA at his
expense; and if judgement is made against AQHA, to pay judgement and obtain written release in form acceptable to AQHA. Through the payment of a membership fee to AQHA, I acknowledge that membership in AQHA is voluntary and agree
to be bound by all the terms and conditions of AQHA’s Official Handbook of Rules and Regulations.
_____________________________________________________________________________________________
SIGNATURE OF PERSON MAKING THIS STATEMENT.
NOT TO BE SIGNED BY RECORD OWNER
_____________________________________________________________________________________________________________________________________
ADDRESS
CITY
STATE/PROVINCE
ZIP CODE
_____________________________________________________________________________________________________
E-MAIL ADDRESS
OWNER’S DAYTIME TELEPHONE NUMBER
AQHA ID NUMBER
________________________________________________________________________________________________________
MAIL CERTIFICATE TO:
AQHA ID NUMBER
______________________________________________________________________________________________
ADDRESS
_____________________________________________________________________________________________________________________________________
CITY
STATE/PROVINCE
ZIP CODE
FEES
FEES SUBJECT TO CHANGE WITHOUT NOTICE.
IF PAYING BY CREDIT CARD, PLEASE COMPLETE THE FOLLOWING:
CHECK
MONEY ORDER
Member
Non-Member
AMERICAN EXPRESS
MASTERCARD
VISA
$30
$70
DUPLICATE FEE:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . .
O
$30
$30
OPTIONAL: Special Handling for 2-day service
. . . . . . . . . .
. . . . . . . . . . . .
CARD NUMBER
This fee is in addition to the regular duplicate fee. Please place “RUSH” on the outside of the envelope.
O
$20
$20
OPTIONAL: OVERNIGHT service
. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . .
EXP. DATE (MMYY)
DAYTIME PHONE
Is available for those who have requested special handling above. This fee is only applicable for service within the
United States and does not include Saturday delivery charges. For those interested in service outside the United
States and / or Saturday services, please contact our office for the correct fee.
CARDHOLDER NAME
Dues payments MAY BE deductible by members as an ordinary and necessary business expense; however, contri-
butions or gifts to the American Quarter Horse Association are not deductible as charitable contributions for federal
CARDHOLDER SIGNATURE
BILLING ZIP CODE
income tax purposes. However, donations to the American Quarter Horse Foundation ARE tax-deductible to the ex-
SUBSCRIBE ONLINE AT
tent allowed by law. $1 of your annual membership dues is designated for a subscription to America’s Horse, AQHA’s
SUBSCRIBING TO THE JOURNAL WILL KEEP YOU
official member publication. Through the payment of a membership fee to AQHA, I acknowledge that membership
UPDATED ON THE AMERICAN QUARTER HORSE INDUSTRY.
in AQHA is voluntary and I agree to be bound by all the terms and conditions of AQHA’s Official Handbook of Rules
DO NOT SEND CASH • U.S. FUNDS ONLY
and Regulations.
-14-159
3-17-15
forms
duplicate certificate front

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