BLACK RUSSIAN TERRIER CLUB

          OF AMERICA, INC.

NAME:

DATE

ADDITIONAL FAMILY MEMBERS APPLYING:

ADDRESS

CITY/STATE/ZIP:

PHONE:

E-MAIL

KENNEL NAME

Occupation

Do you approve of the club’s use of e-mail to contact you on important club matters?

YES

NO

Signature

__________

AREAS OF INTEREST (check all that apply);

__Conformation Showing,    __ Obedience,

__Schutzhund,  __Therapy Dog,  __ Breeding,   __Judging,  __ Personal Companion

__Agility, __Rally

LIST OTHER ALL-BREED OR SPECIALTY CLUBS TO WHICH YOU BELONG AND

OFFICES HELD (if any)

Number of Black Russian Terriers Currently Owned

# Co-Owned

Registered Names and Reg # on BRTs currently owned:

Other Breeds Owned:

Special Skills or Abilities you feel might be useful to BRTCA:

Committees you might be interested in serving on:

Health

Constitution and By-laws

Standard

Rescue

Obedience/Working Dog Sport

National Specialty and Special Events

Ways & Means

If elected to membership, I will abide by the Constitution, By-laws, and the Code of

Ethics of the Black Russian Terrier Club of America, Inc., and the rules and regulations

of the American Kennel Club. 

(signature of applicant)

(date)

(signature of co-applicant)

(date)

Page 2

Do you approve of your contact information being posted in the following medium:

Website

Newsletter

Membership Directory

Each applicant must be sponsored by two members in good standing of the BRTCA who are not related to the applicant.

(sponsor signature)

(sponsor signature)

Membership dues:

Individual ($25) eligible to anyone over 18 who owns a registered BRT.

Family ($30) for joint membership plus  $5 for every additional member under

18. Also must own a registered BRT.                                                                   Associate ($25) available to anyone over 18, no dog ownership required.

 Associate members have no voting privileges, and require no sponsors.

See By-Laws and Consititution for full membership requirements.

Please send completed application and check made payable to BRTCA to:

Dana Kellerman

5621 N. Kenmore

Chicago, IL  60660