Membership Application

(Required field are marked with an ( * ))

* First Name:

* Last Name:

Partner's First Name:

Partner's Last Name:

* Address:

* City:

* State:

* Zip:

-

* Phone:

() -

* EMail:

Kennel Name:

Do you own a Shiloh?
Yes No

If yes, please indicate quantity:
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 Shiloh in the future?
Yes No

Do you plan on showing/breeding your Shiloh if
he/she has all the quality requirements?
Yes No

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

Agility Flyball Search & Rescue Therapy

Obedience:
Novice
Open
Utility

Schutzhund Herding

Other:

Please state your past experience in showing/breeding:

* 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):

Individual ($15.76)

Partner ($10.61)