APPLICANT: ______________________________ NAME OF DOG:____________________________________

NAME:___________________________________________

Address:_____________________________________________________________________________________

Phone: (    )________________________

MEMBERSHIP STATUS: Active___________ Associate____________

CLUB PLAQUES: I am applying for: (Circle appropriate award number.)

C1 (Date of completion & Show)_________________________________________

C2 (Date & Show of completion)CD _______________ CDX_____________ UD______________ OTCH_________________

C3 (Date & Show)______________________

C4 (Date & Show)___________________________________________________

C5 (Date & Show)___________________________________________________

C6 (Date & Show)____________________________________________________

C7 (Date & Show)____________________________________________________

C8 (Date & Show)____________________________________________________

C9 (Show/s & Date/s)_________________________________________________

ACHIEVEMENT AWARDS : I am applying for:

Circle the appropriate award number and on a separate sheet list dates, shows, and/or other pertinant information.

A1_________________ A7_________________ _A13__________________

A2_________________ A8_________________ _A14__________________

A3_________________ A9__________________ A15__________________

A4_________________ A10________________ _A16__________________

A5_________________ A11_________________ A17__________________

A6_________________ A12 _________________A18__________________

A19_________________A20_________________A21__________________

A22_________________A23_________________A24___________________

A25_________________A26_________________A27___________________

PERPETUAL AWARDS: I am applying for:

Circle the appropriate award number and on a separate sheet list the dates and shows.

P1____________ Name of Dam____________________________________
List Champion get and date of completion on a separate sheet.

P2____________ Name of Sire_____________________________________
List Champion get and date of completion on a separate sheet.

P3_____________________________ P7___________________________

P4_____________________________ P8___________________________

P5_____________________________ P9___________________________

P6_____________________________ P10__________________________

P11. Name________________________________________________

P12. Date of Completion_______________________________________________

P13. Titles and Dates of Completion_______________________________________