WORKING SAMOYED CERTIFICATE - DOC

							                           WORKING SAMOYED CERTIFICATE
               THERAPY DOG CERTIFICATE VERIFICATION FORM
Dog’s name:__________________________________________________

Registration Number: __________________________________________

Owner’s Name: ______________________________________________

Owner’s address: _____________________________________________

               ______________________________________________


INSTITUTION                        ADMINISTRATOR’S                HRS         DATE
                                     SIGNATURE

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Total hours: __________________


                                                                         December 2004