Name _________________________________________________________________________

Address ________________________________________________________________________

___________________________________________ Postal Code _________________________

Telephone ________________________________ Fax __________________________________

Email __________________________________________________________________________

I have enclosed my membership dues of $20.00 _______  Family Rate $35.00 _________

My main interests are: Conformation (  ), Obedience (  ),  Field (  ),  Other _______________________

I am a member of the Canadian Kennel Club:  Yes (  ) # _____________, No (  ).

I am a breeder:  Yes (  )  No  (  )

I own the following breeds: ___________________________________________________________

I have a Registered Kennel:  Yes (  ), No (  ). Name: ________________________________________

I am interested in the following activities:

Education                                             Community Activity

(  ) Mall Information Booth                    (   )  Visiting Nursing Homes with my dog

(  ) School Visits                                  (   )  Annual Dog Walk-A-Thon

(  ) Government Lobbying

Dog Shows

(   ) Judging

(   ) Ring Steward in: (   ) Conformation  (   ) Obedience  (   ) Field Trials  (   ) Agility

(   ) Learning more about the role and function of officials.

What background, experience, resources or hobbies do you have that would benefit the club?

__________________________________________________________________________________

Date: _____________  Signature(s) ______________________________________________________

For further information contact:  

Kathy Patten-Heal

Membership Chair

267 Delta Place

London, Ontario N6J 3N1

Phone: (519) 641-6688 Fax: (519) 473-7508 

Email:  london.canine@sympatico.ca

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