NAME:_______________________________________________ Birthday  (m/d)  ____/_____

NAME:_______________________________________________  Birthday (m/d)  _____/____

ADDRESS: ________________________________________________  Phone (     )        -            

CITY: _______________________________  STATE; _____________ ZIP: ________________

OCCUPATION: ______________________________________________

EMAIL ADDRESS: ____________________________________________
I/We agree to abide by the Constitution and By-Laws, and Rules and Regulations of the
HOOSIER STATE CHINESE SHAR-PEI CLUB

Signature: ______________________________________________________  Date: _____________

Signature: ______________________________________________________   Date: _____________

Sponsor's Signature: _________________________________________________________________
 

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We WELCOME and encourage your participation.  This Club is for the members and their dogs.
What areas of interest do you have?
Is your Shar-Pei for:  Pet _____ Show _____ Obedience _____ Breeding _____
How many Shar-Pei do you own? _____  Other Breeds? _____

List Shar-Pei you own:
Name: _____________________________________________________ AKC # _______________

Name: _____________________________________________________ AKC # _______________

Name: _____________________________________________________ AKC # _______________

SKILLS - SERVICES - FACILITIES - THAT YOU COULD ASSIST THE CLUB
Meeting Place: _____ Assist at Shows: _____ Club Officer: _____ Make Phone Calls: _____
Other: (Please Explain) __________________________________________________________________
FOR OFFICE USE ONLY
Date Application received __________  New Membership __________ Renewal _________
Amount Received ________  Check ______ Cash ________
Date Membership Application read at Meeting ______________
Date Voted on for Membership _____________ Accepted  YES / NO
Reason if not Accepted ________________________________________
Signature ______________________          This is a permanent and official record of the H.S.C.S.P.C