MEMBERSHIP INFORMATION

EASTERN STATES WORKING DOG ASSOCIATION, INC

MEMBERSHIP INFORMATION

If you are interested in joining the Eastern States Working Dog Association, fill in the form below, PRINT AND MAIL TO THE ADDRESS AT THE BOTTOM OF THIS FORM.

All Information Required except for Comments

Membership Status: New Renewal

FIRST NAME: LAST NAME:

ADDRESS: CITY:

STATE: ZIP CODE: TELEPHONE NUMBER:

EMAIL ADDRESS:

YEAR OF BIRTH:

(AGENCY AFFILIATION'S)

AGENCY NAME:

ADDRESS:CITY:STATE: ZIP: PHONE:

HANDLER INFORMATION

LIST TYPE OF CANINE BY BREED AND TRAINING:

CERTIFYING AUTHORITY:

CANINE INFORMATION

1. BREED: NAME: AGE:

2. BREED: NAME: AGE:

3. BREED: NAME: AGE:

4. BREED: NAME: AGE:

5. BREED: NAME: AGE:

LIST PREVIOUS K9 TRAINING:

MEMBERSHIP INFORMATION

MEMBER-$35.00/YEAR

ASSOCIATE MEMBER - $25.00/YEAR

PLEASE COMPLETE BEFORE PRINTING THIS FORM AND MAIL, WITH THE APPROPRIATE FEE IN THE FORM OF A CHECK OR MONEY ORDER TO:

E.S.W.D.A.

P.O. BOX 187

MOUNT HOLLY, NJ 08060

Then select the SUBMIT button.

To Pay Membership Fee online, complete and Submit Form.

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