Please complete this form, print it out, and mail it along with your $30 membership dues and nomination fee (YOU MUST INCLUDE a copy of your stamped Certified ND Bred papers with initial nomination) to:

North Dakota Quarter Horse Association
PO Box 634
Bismarck, ND 58502

Horse's Name:
Stallion:
Mare:
Owner:
Address:
State:	ZIP:
Phone:
Email address:
Race(s) interested in entering:	Futurity Derby Diemert