|
|
Membership Application NAME_______________________________________________________________ DATE__________________________ ADDRESS_________________________________________________ City_______________________________________ STATE/COUNTRY/ZIP CODE___________________________________________________________________________ PHONE ______________________________________________FAX____________________________________________ E-MAIL______________________________________________________________________________________________ Kennel Name__________________________________________________________________________________________ Occupation___________________________________________________________________________________________ Have you ever applied before? ( ) Yes ( ) No If yes, When?_____________________________________________________ Areas of Interest: (Check all that apply): Showing Confirmation ______Obedience_________ Personal Companion______________ Schutzhund__________ Service to Handicapped___________ Breeding ____________Judging__________________ List other All-breed or Specialty Clubs to which you now belong and offices held (if any). _____________________________________________________________________________________________________ Owner of how many Black Russian Terriers?____________________________________________________________________ Co-owner of how many Black Russian Terriers?_________________________________________________________________ Black Russian Terriers you presently owned (Please print and use complete registered names of dogs and pedigree number) ______________________________________________________________________________________________________ Other Breeds owned: _____________________________________________________________________________________ Special skills and abilities you possess which might be helpful to the BRTCA: _______________________________________________________________________________________________________ If elected to membership, will you be willing to serve on a committee(s)? ( ) Yes ( ) No Please check the Committee (s) on which you would be interested in working. Advertising/Catalog______ Health______ FundRaising______ Picnic_____Sunshine______Match Show_______Trophies______ Audio/Photography_______ Historian/Librarian_______ Public Education______ Publicity_______ Budget_______ Membership_______ Rescue_______ Club Property______Newsletter_______ ********************************************************************************************************* If elected to membership, I hereby agree to 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. No member will enjoy voting if his/her dues are in arrears. Any member voted in after November 1st dues will be applied to the following year. Dues shall become due on January 1st of each year. ________________________________________________________________________________________________________ Signature of Applicant Date Do you approve of your contact information being posted on: Web-site: ( ) Yes ( ) NO Newsletter: ( ) Yes ( ) NO Any Publication: ( ) Yes ( ) NO (please check) ANNUAL DUES Check the appropriate Membership: * NEW REQUIREMENT - All New Members must complete one full calendar year as an associate member . Individual ( ) - Regular Membership � ($25.00 US Dollar per year) open to any owner 18 years or older of a registered Black Russian Terrier Family Membership ( ) � ($25.00 plus $5.00 for each additional family member over 18 years of age) open to any owner 18 years or older of a registered Black Russian Terrier Associate Membership ( ) � ($25.00 US Dollar per year) open to non-owners 18 years or older and do not own a registered Black Russian Terrier. An Associate membership does not have voting privileges. Your membership fees will be deposited upon the acceptance of your membership. Payment must be made in U. S. Funds and payable to Black Russian Terrier Club of America, Inc. THE FOLLOWING PORTION TO BE COMPLETED BY TWO SPONSORS Each applicant must be sponsor by two BRTCA members who are not related to applicant or each other and the BRTCA Sponsors have been members in good standing for at least a minimum of 2 years. We, the undersigned BRTCA members do individually recommend this applicant: Name of Sponsor (please print) Signature of Sponsor Date ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please send Application to: Cecilia Charles 605 Magnolia Road Lumberton, MS 39455 Phone: 601-528-9581 **NOTE*** Both pages (1 and 2) must be completed and forward with check to above address. *************************************************************************************************** THE FOLLOWING PORTION IS FOR CLUB USE ONLY Application Received by Membership Committee______________________________________________________________________________________ Sent Constitution, By-laws & Code of Ethics_________________________________________________________________________________________ Read Application at Board Meeting _______________________________________________________________________________________________ Voted on___________________________________________________________________________________________________________ Sent Acceptance Letter_________________________________________________________________________________________________________ Dues paid_________________________________________________________________________________________________________ |