Longevity Certificate Application

Type or Print the following information and include copies of documentation:
Registered name including titles:
Registration #:
Registry (AKC, CKC, or FCI, etc.):
Sire's registered name including titles:
Dam's registered name including titles:
Copy of Registration is required and must be submitted with the application.
Birth Date: // (mm/dd/yy)
Date of Death (if applicable): // (mm/dd/yy
Sex: Male Female
Spayed/Neutered: Yes No Age of Spay/Neutered:
Cause of Death (Optional, but desirable):

Owner:
Address:
City:
State: Zipcode: Country:
Phone: -- E-mail:
Co-Owners:
Address:
City: State: Zipcode:
Country:
Phone: -- E-mail:
Breeders:


Verification of date of death or proof that the dog is still living is required and must be submitted with the application. This could include a statement from your Veterinarian or a MCOA Member (other than yourself) in good standing with signature, memorial ad, etc.

Print and mail, e-mail or fax the completed application and copies of documentation to: Diana Van Sandt

MCOA LC Program
13925 Murphy Road
Peyton, CO 80831-9510
Phone/Fax: (719) 749-0035
farpoint@vansandts.com You can submit this form electronically, BUT you will still need to send additional documentation to the MCOA LC Program coordinator.


To submit your data press here:    To reset the form, press here: .

MCOA Health Committee:
Co-Chairs:
Anna May (951) 704-6022 mastiff@iinet.com  
Jenny Zinn-Boyce (562) 425-8354 jzinnboyce@aol.com    

Members:

Jan McNamee (330) 648-9427 windfallmastiffs@hughes.net 
Dr. Bill Newman (814) 623-9377 dansdad@pennswoods.net  

Subcommittee chairs:

Cancer - Jenny Zinn-Boyce (562) 425-8354 jzinnboyce@aol.com
Cystinuria - Beth Nichols (262) 859-0347 bethmastiff2@aol.com 
Cystinuria - Lisa Edwards-Filu (845) 477-0233 darkmstf@yahoo.com
DNA - Mary DeLisa (303) 929-5529 mwhipple75@aol.com
Health Awards - Karen Flocker (480) 632-5240 mastiffmom@cox.net
Hip - Elbow Dysplasia  Tammy Sholes (828) 428-3355 nicochri@bellsouth.net
PRA - Carla Sanchez (951) 696-4169 CARLACHEZ@aol.com
Seizure Disorders - Doreen Dysert (503) 348-9347 ddysert@hughes.net

Established in 1997 by Constance Parker.