Horse & Dog Club Certificate Request

Name of Club *

Club Contact

First Name *

Last Name *

Club Mailing Address

Street Address *

City *

State *

Zip *

Email Address *

Phone Number

Fax Number

Certificate Needed By *

Event Information

Name of Event *

Event Dates *

Address Where Event Held

Street Address *

City *

State *

Zip *

Certificate Holder #1

Provide Certificate Holder Details Below

Select One *

NOTE: Please refer to your contract in selecting the appropriate type of certificate.

Proof of Insurance

Additional Insured (AI)

Check all that apply *

Landowner

Facility Owner

Sponsor

Equipment Lessor

Other

Certificate Holder Name *

Mailing Address

Street Address *

City *

State *

Zip *

Email

Fax Number

Notes

Certificate Holder #2 (if necessary for same event)

Provide Certificate Holder Details Below

Select One

NOTE: Please refer to your contract in selecting the appropriate type of certificate.

Proof of Insurance

Additional Insured (AI)

Check all that apply

Landowner

Facility Owner

Sponsor

Equipment Lessor

Other

Certificate Holder Name

Mailing Address

Street Address

City

State

Zip

Email

Fax Number