LaSalle Brittany Club Membership Application

Please indicate below which annual membership is being applied for:
New Member ($35.00) | Renewal ($35.00) | Associate Member ($10.00)
Any person may become an Associate Member, as one's choice of membership, when a member of one's immediate family is an Active Member.

YOUR CONTACT INFORMATION
Your Name:
Spouse:
Address:
City:
State: Zip:
Phone:
E-mail:
Occupation:
Dogs Owned:
Are you 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
Show
Obedience
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: _______________________________________________________________
.

To reduce mailing costs, we will send newsletters and occasional notices via email. If you do not have an email address, you will receive the newsletter via U.S. Mail 7-10 days following the email to membership. Occasional notices will be emailed to members and posted on the web site but will not be mailed via U.S. mail. Your email address will not be shared with any other person or organization without your permission.

Please print your completed application and mail with your check (payable to LaSalle Brittany Club) to:
Tim Cummings, 26W 526 Blair St., Winfield, IL 60190
or pay your membership dues on line by clicking the button below*:
*a $2.50 service fee applies when paying online