Name:___________________________________________________________________________________

Address:________________________________________________________________________________

City:________________________________ State:______________ Zip Code:____________________

Telephone - (H)____________________ (W)____________________ (FAX)_______________________

Dog Name:_____________________________________ UKC #______________ D.O.B._______________

Dog Name:_____________________________________ UKC #______________ D.O.B._______________

Dog Name:_____________________________________ UKC #______________ D.O.B._______________

Membership type desired (check one):  

___Individual ($20 annual fee)   ___Family ($25 annual fee)

If family membership, please list names below:

______________________________________ Relationship:____________________________________

______________________________________ Relationship:____________________________________

______________________________________ Relationship:____________________________________

Are you a member of any other retriever club(s)?   ___Yes   ___No

Retriever Club(s) names and addresses:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

_______________________________________		___________________________
Signature of Applicant 				Date