|
Name |
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Home
Phone # |
Cell
Phone # |
|
Address |
|
|
|
City |
|
State |
|
Zip Code |
|
|
E-mail |
|
Kennel Name (if applicable) |
|
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Do you plan on
purchasing an ISSR Shiloh in the future?
q
Yes q
No
Do you currently own any
Shiloh Shepherds? q Yes (please specify below)
q No
(Note: If more
than three Shilohs are owned, please list details on back of this form.) |
| |
Registered
Name |
Breeder's
Name and/or Kennel Name |
ISSR
Registered? |
Date
of Birth |
Sex |
|
Shiloh #1 |
|
|
qYes qNo |
|
qM qF |
|
Shiloh #2 |
|
|
qYes qNo |
|
qM qF |
Shiloh #3 |
|
|
qYes qNo |
|
qM qF |
|
Do you plan on
showing/breeding your Shiloh if he/she has all the quality requirements?
q
Yes q
No |
|
What activities do
you participate in with your Shiloh? (Check any that apply): |
|
q STM |
q Agility |
q Search & Rescue |
q Flyball |
q Schutzhund |
|
q Therapy |
q Herding |
q Obedience |
q Novice |
q Open |
|
q Utility |
q Other (Please describe) |
Do you have any experience in
showing, training or breeding dogs? |
|
|
|
|
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Are you a current member of the
SSDCA*? q Yes
q No |
Member # |
|
# of Years |
|
|
*All NASSA members
must be current members of the parent club, the Shiloh Shepherd Dog Club of America,
Inc (SSDCA) |
|
Would you be
willing to function in any particular office or any committee?
q Yes q
No
Or is there any service for the chapter that you would be willing to
perform?
____________________________________________________________________ |
|
With my signature, I agree to abide by the Constitution and by-laws of the SSDCA, the
Breeders Code of Ethics, and the Chapter’s
Policies and Procedures
Handbook. All the
information given above is correct to the best of my knowledge.
Signature:____________________________________________________ Date:
_____________________
|
Annual Fee:
$15.00 Total Payment
Enclosed: $ |
q
New Member
q
Renewal |
|
- - - - - For Office Use
Only - - - - - |
|
Date Received |
|
Amount Paid |
|
NASSA Member # |
|
|
Received by |
|
Membership Dates: |
From |
|
To |
|
|
Please mail to: Debbie Knatz 32 East Margin Road Ridge, NY 11961 |
