BRTCA New 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_______
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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. Example: Husband and Wife Membership fee $30.00; Husband, Wife and one Child $35.00 etc. each additional
person in a family membership is $5.00
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: June Charles 605 Magnolia Road Lumberton, MS 39455 Phone: 601-928-8384
**NOTE*** Both pages (1 and 2) must be completed and forward with check to above address.
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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________________________________________________________________________________________________