First Name: __________________________ Initial: ___ Last Name: ________________________

Address:_______________________________________________________________________

City: ____________________________ State: ______ Zip Code _______________-___________

E-mail _____________________________________ Phone: _____________________________

How long have you been a chow owner? ________ Years ________ Months

How many chows do you currently have? _________

How did you hear about us ? Web Page _____ Club Member ______ Other _______

If "Other" please specify: _____________________________________________________________ 

Reasons for joining the NFCCC: _______________________________________________________

 

________________________________________________________________________________

 

________________________________________________________________________________

If applicable, please enter your kennel name: ______________________________________________

Please list other dog clubs you belong to: ________________________________________________

 

________________________________________________________________________________

 

________________________________________________________________________________

Are you over 18 years of age? Yes / No _________

Sponsor 1 Name __________________________________ Date:__________________________

Sponsor 2 Name __________________________________ Date:__________________________

 

Signature: _______________________________________  Date:__________________________

Mail to:

Terry Tapp

5637 SW 282 Street

Newberry FL 32669-4330