Membership Application

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Contact:

Sue Carrier

1185 W. Comet Rd

Clinton, OH 44216

(330) 882-2338

Membership Application - One Year Membership

Name: ______________________________________________

Telephone Number: (______)-________-___________

Address: __________________________________________________________________________________________________________________________City: ___________________________________________

State: __________________ Zip: ____________________

Email: __________________________________________

GETTING TO KNOW YOUR DOG

Kennel Name: _____________________________________

( if you are a breeder)

Do you own a Shiloh? ______________

If yes, please indicate number:
DOG __________________ BITCH _________________

Registered Name: ________________________________________________

Date of birth: _____________________

Sire: _____________________________

Dam: ______________________________________________

From whom did you purchase your Shiloh?
____________________________________________________________

Do you plan on purchasing another Shiloh in the future? ____________________________________________________________

Do you plan on showing/breeding your Shiloh if he/she has all the quality requirements? _______________________________________

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

Flyball

Search and Rescue

Obedience

Novice

Open

Utility

Therapy
Schutzhund
Herding
Other (please describe)_______________________________

Please state your past experience in showing/training/breeding below.

Are you a member of the SSDCA? _____________

For how many years?__________

SSDCA Membership #___________________

GETTING TO KNOW YOU

Are you: Married Single (please circle)

Do you have children? Yes No (please circle)

If yes, please list their names & ages: _______________ _______________ ____________________ _________________ __________________ ________________

What led your family to the choose the Shiloh Shepherd?

What kinds of activities would you like to see the NBC chapter sponsor? All NBC members must be members of the parent club, the Shiloh Shepherd Dog Club of America, Inc.

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?___________________________________________________________

With my signature, ___________________________________________________________

I agree to abide by the Constitution and by-laws of the SSDCA and the Breeders Code of Ethics.

All the information given above is correct to the best of my knowledge.

Please include a payment of:$10.00-Junior Member. (This membership is if you do not own a Shiloh).

Should you purchase a Shiloh in the future you will need to upgrade to a Family membership.
$20.00- Family Member

For Office Use Only
Date Received: _______________________ Membership Dates:
Amount Paid: ________________________ From: ________/_________/_________
NBC Membership # __________________
To: ________/_________/_________