Membership Application

Name *

Address *

City *

State *

ZIP Code

Phone

Email Address *

Breed(s) Owned (Past & Present)

Litters bred within the past 3 years

Have you exhibited at matches, shows, trials?YesNo

If yes, which?Select all that apply.

Have you ever been refused membership in another dog club or organization?YesNo

If yes, please explain.

Have you ever been reprimanded, expelled or placed on probation by the AKC or any other governing Club?YesNo

If yes, please explain.

List membership(s) in other dog clubs and offices held (if any)?

Which sport(s) are you interested in?Select all that apply.

A willingness to work on committees is the backbone of any club organization, please list any skills that you feel you could contribute:

Which club-sponsored event(s) are you willing to assist with?Select all that apply.

Membership Level Applying ForSelect OneASSOCIATE – Available to individuals and households. Welcome at meetings and club functions. Encouraged to be a working participant in a club activity. Cannot vote or hold office and not eligible to receive club awards. Dues are $20 per year for Associate Individual or Associate Household.REGULAR – Welcome at the club’s monthly business meetings and encouraged to be a working participant in at least one club activity and function per year. Entitled to vote, hold office, and receive club awards. Dues are $15 per year.HOUSEHOLD – Available to households consisting of two adults, with or without children under 18, residing under one roof. Welcome at all meetings and club functions. Entitled to one vote per adult over 18; may hold office and receive club awards. Dues are $20 per year.JUNIOR – Open to individuals who are 10-17 years of age. At the end of the calendar year in which they attain their 18th birthday, Junior members must apply for membership as Active or Associate members. Dues are $10 per year.

Junior's Birthdate

Applicant Signature *

Date *

Signature of Second Applicant

Date

Payment *