Membership Page

American Working Black Russian Terrier Association

(AWBRTA)

Application Form

Single Membership: $30.00
Family Membership: $40.00 (2 persons at the same address)
Youth Membership: $10.00 (Age 21 and under)
Single Foreign Membership: $40.00
Family Foreign Membership: $50.00

AWBRTA MEMBERSHIP APPLICATION

First Name __________________________ Last Name _______________________________________

Address _____________________________________________________________________________

City _________________________________ State _____________________ Zip __________________

Home Phone ( ) __________________________ Daytime Phone ( ) ____________________________

E-Mail __________________________________________ Fax # _________________________

AWBRTA is a volunteer based organization, we look to our members for help on occasion. Do you have a special talent or skill or experience that you think might benefit the organization at some time in the future? Please elaborate:_____________________________________________________________

_____________________________________________________________________________________

Mail to: U.S. funds only. No foreign checks or drafts. Make check payable to AWBRTA.

American Working Black Russian Terrier Association (AWBRTA)

Patty Bartley

P O BOX 343

Elbert, CO 80106

As a member of the American Working Black Russian Terrier Association, I shall do my best to uphold its objectives and ideals, as provided in its By-laws, rules and regulations; and I shall conduct myself in a sportsmanlike manner at all times.

Signature: ___________________________________Date: _______________

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FOR AWBRTA SECRETARY USE ONLY:

From: ____________________ To: ______________________

Date Paid __________ Total Amount Paid $ _________________

Circle: New Member Renewal Honorary Membership