Name:

Phone:

Address:

E-Mail

Individual Membership

$10.00

c

Household Membership

$15.00

c

Associate    

$5.00

c

Are you a member in Good standing with the American Kennel Club? If no, please  explain:

Yes:     c        No:  c

Are you a member of any other dog club, single or all-breed?

Yes:  c     No:  c

Have you held office in another club?

Yes:  c     No:  c

Do you own one or more Japanese Chin?

Yes:  c     No:  c

Do you own?   c

Breed?  c

Exhibit?  c

Other breeds?

 Yes:     c      No:     c

Are you a professional in any of the following?

Grooming?   c        

Training?  c                 

Show Handling?  c

Boarding Kennel? c

Pet Supplies?    c

Judging?       c

 Kennel Name Used

Are  your Chin. Identified?  

Tattoo: c  Microchip:  c

 Are you willing to Serve on a Committee of JCCWPA

Yes:     c      No:     c

Are your Chin registered with the AKC?

Yes:     c      No:     c

Are you willing to work for the Advancement of the Chin Fancy?

Yes:     c      No:     c

Indicate the areas of interest. (check all that apply)

Conformation:c Obed:c

 Agility: c  Breeding: c