MEMBERSHIP APPLICATION

The undersigned hereby applies for membership in the NORTHERN CALIFORNIA TERRIER ASSOCIATION (NCTA), and agrees, if elected to such membership, to abide by the rules of the AMERICAN KENNEL CLUB (AKC) and the Constitution and By-Laws of the NCTA. Please print.


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LAST NAME FIRST NAME MIDDLE INITIAL OCCUPATION
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STREET ADDRESS CITY/STATE ZIP CODE (9 digits)
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HOME AND/OR WORK TELEPHONE NUMBER(S) (Please Specify) FAX

KENNEL NAME E-MAIL
List other dog clubs of which you are currently a member and indicate any club offices you have held.
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How do you classify yourself? (Check all that apply) ( ) Breeder ( ) Exhibitor ( ) Judge ( ) Dog Owner
How many dogs do you currently own?_____ Complete the following for no more than two dogs you currently own:
Breed Registered Name Sire & Dam AKC Registration Number
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List all AKC litters that you have welped in the last 2 years:
Breed Sire & Dam Date Litter Whelped Litter Registration Number
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If you are an exhibitor, in which year did you first become active? _______ . List two recent shows at which you have exhibited a dog. __________________________________________________________________________
If you are a breeder, in which year did you breed your first litter? ________ If you are a Judge, in which year did you first begin? ______.
List up to two titles you have earned in the last two years:
Breed Registered Name Title Earned

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First Meeting Attended ________________________
SPONSOR SIGNATURES (1)_______________________________________________ DATE ____________
(2)_______________________________________________ DATE _____________
YOUR SIGNATURE: ______________________________________________________ DATE _____________
Initiation Fee: $20.00 Please return the completed application (with a check or money Annual Dues: $15.00 order payable to NCTA)
Total Amount Due: $35.00


NCTA USE ONLY: Date Received: _______________ Date of Board Action: ____________
Date General Membership Action: _____________ Date Applicant Notified: ____________
Date Membership Became Inactive: ____________________ REV 3/2000

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