Membership Application

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Membership Application One Year Membership

First Name:_______________________ Last Name:_____________________________

Partner’s First Name:_______________ Partner’s Last Name:_____________________

Address:_______________________________________________________________

City:______________________________ State: _________ Zip: _______-______

Email:_______________________________________Phone: (____) ____-______

Kennel Name: _________________________________________________________

Do you own a Shiloh? If yes, please indicate quantity:

Yes No DOG(s): BITCH(es):

Registered Name:______________________________Date of birth:_______________

Sire:___________________________ Dam:_______________________________

Registered Name:_________________________________Date of birth:_____________

Sire:_________________________________ Dam:_____________________________

Registered Name:_________________________________Date of birth:_____________

Sire:_________________________________ Dam:______________________________

Do you plan on purchasing another Do you plan on showing/breeding your Shiloh if

Shiloh in the future? he/she has all the quality requirements?

Yes No Yes No

What other activities do you participate in with your Shiloh? (check all that apply)

Agility Flyball Search and Rescue Therapy

Obedience: Novice Open Utility Schutzhund Herding

Other:

Please state your past experience in showing/breeding:

If asked, would you be willing to function in any particular office or any committee, or is there any service for the chapter that you would like to perform?

SSDCA Membership #:_________________________________

(All SSDCA-MAC members must be members of the parent club)

By submitting this form with the membership fee below, I agree to abide by the constitution and by-laws of the SSDCA and, if a breeder, the Breeder’s Code of Ethics. All the information given above is correct to the best of my knowledge.

Membership(s):

Personal Check PayPal*

Individual ($15) Individual ($15.76)

Partner ($10) Partner ($10.61)

*Additional cost covers PayPal’s $0.30 & 2.9% fees

For payment instructions please go to instructions page

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