Please complete this form, print, and mail with your check, payable
to LaSalle Brittany Club,for $35 to:
Lou Smith, 3452 Cyclone Rd., Earlville IL 60518
|
| Last Name |
______________________________ |
First Name
|
______________________________ |
| Spouse |
______________________________ |
Phone |
(_______)______________________ |
| Address |
____________________________________________________________ |
| City, ST, Zip |
____________________________________________________________ |
| Occupation |
____________________________________________________________ |
| # Dogs Owned |
____________________________________________________________ |
| Willing to serve on a committee? [___]
YES [___] NO |
| Primary Interests: Mark
1-5, #1 being of most interest, #5 being the least interest: |
| [___] Field Trials [___]
Hunting [___] Obedience [___]
Showing [___] Pet [___] Other |
| |
| I/We, __________________________________________________hereby
apply for membership in the LaSalle Brittany Club, and enclose appropriate
dues and initiation fees. It is understood that if this application
is rejected for any reason, my money will be refunded. My signature
below will signify my willingness to abide by the rules and regulations
of the LaSalle Brittany Club, Inc. |
| SIGNATURE(S) |
____________________________________________________________ |
| |
____________________________________________________________ |
| DATE |
______________________________ |
