NORWICH TERRIER CLUB OF NORTHERN CALIFORNIA
MEMBERSHIP RENEWAL FORM FOR 2011-JANUARY 1,2011-DECEMBER 31, 2011
DEADLINE DATE FOR RENEWAL 12/31/2010
PLEASE PRINT
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PLACE LABEL ON HERE |
PLEASE MAKE ANY CORRECTIONS IF THERE HAS BEEN A CHANGE OF YOUR INFO ON THE LABEL TO YOUR LEFT.
FIRST NAME_______________________LAST NAME______________________________
FIRST NAME_______________________LAST NAME______________________________
MAILING ADDRESS__________________________________________________________
CITY____________________________STATE_______________________ZIP___________
PLEASE UPDATE YOUR PHONE NUMBER AND EMAIL ADDRESS.
CELL PHONE #_____________________HOME PHONE #___________________________EMAIL ADDRESS____________________________
YOU ARE CURRENTLY A _______________________MEMBER. DO YOU WISH TO CHANGE YOUR MEMBERSHIP TYPE? YES_____ NO______
MEMBERSHIP TYPES (PLEASE MAKE CHECK OUT TO NTCNC)
JUNIOR MEMBERSHIP-$12.50 _____
ASSOCIATE MEMBERSHIP-$20.00____
SINGLE-$30.00_____
HOUSEHOLD-$35.00____
1) DO YOU CURRENTLY OWN A NORWICH TERRIER? (PLEASE CHECK ONE) YES______NO_____
2) I,(WE), WISH TO RECEIVE CLUB NOTIFICATIONS BY (CHECK ONE) EMAIL__________ or US MAIL________
3) WOULD LIKE TO MAKE A DONATION TO THE CLUB? (CHECK ONE) YES_______NO_______
4) IF YES, WHAT IS THE AMOUNT OF THE DONATION? __________
DO-DOG OWNER_____
E-EXHIBITOR IN CONFORMATION______ PLEASE MAIL CHECK TO:
B BREEDER______ MARCIA EDWARDS, TREASURER O-OBEDIENCE____ 3825 Selvage Road J-AKC JUDGE______ Santa Rosa, CA 95401 A-AGILITY______ R-RALLY____ ED-EARTH DOG_____ T-PET THERAPY_____
PRINT(1) SIGNATURE_______________________________________________________________DATE_______
SIGN (1) SIGNATURE________________________________________________________________DATE________
PRINT (2) SIGNATURE_______________________________________________________________DATE________
SIGN (2) SIGNATURE________________________________________________________________DATE_________