Prince Edward Island Ladyslipper/Joe O’Brien Series/Island Breeders Series

Broodmare Declaration Form

For broodmares, whose owners reside outside Prince Edward Island and who were on
Prince Edward Island for a minimum of 183 days in the foaling year and whose offspring
are being nominated to the Ladyslipper/Joe O’Brien Series/Island Breeders Series.
Nominations are subject to the terms and conditions of the Ladyslipper/O’Brien
Series/Island Breeders Series as approved by the Atlantic Provinces Harness Racing
Commission.

Information pertaining to the broodmare(s) who resided on Prince Edward Island for a
minimum of 183 days during the year 20_____:
Broodmare Owner Province Telephone #

Information pertaining to the farm/property where the above broodmare(s) resided for a
minimum of 183 days in the Province of Prince Edward Island in 20_____:

Farm/Property Owner/Manager Address

Telephone #

_______________________________________________

____________________
_______________

_______________________________________________

CANADA
PROVINCE OF PRINCE EDWARD ISLAND
IN THE MATTER OF:
The Prince Edward Island Ladyslipper/Joe O’Brien Series/Island Breeders Series

I, ___________________________, of ________________, in the County

of_____________, Province of Prince Edward Island, Farm/Property Owner/Manager do
solemnly declare that:

1. I am the person who owns or did own/manage the farm/property on which the
broodmare(s) described in the Broodmare Declaration Form (reverse) resided during the
________ calendar year.

2. The matter and facts in the Broodmare Declaration Form are true, to my own
knowledge; and

3. I understand in the case of information in the Broodmare Declaration Form not being
correct that the mare described therein would be declared ineligible for the Prince Edward
Island Ladyslipper/O’Brien Series and my farm/property or I would be liable to reimburse
all purse money earned by the farm, myself or the buyer of the applicable offspring and my
farm or I would be ineligible to participate in the Prince Edward Island Ladyslipper/O’Brien
Series in the future.
And I make this solemn declaration conscientiously believing it to be true and knowing that
it is of same force and effect as if made under oath.

County of ___________, Prince Edward Island,) this _____ day of _____________,

20_____)

_____________________________
___________________________________________
Name and Signature of Farm/Property Owner/Manager