ROLLA MISSOURI KENNEL CLUB, INC. 
New Member Application

Name:____________________________________________________________________

Address:__________________________________________________________________

Telephone Numbers  (Home) ____________________  (Cell) _______________________

Occupation:________________________________________________________________

TYPE OF MEMBERSHIP DESIRED: 	Student Dues 	$5.00/Yr.
Regular Dues 	$10.00/Yr.
Family Dues 		$15.00/Yr.

BREED(S) OF SPECIAL INTEREST:

FIELD(S) OF INTEREST:

Conformation  Obedience   Tracking   Herding    Junior  Field/Hunting Test/Working Certificate                    

I AM  (please circle one):            Breeder                Exhibitor               Interested Dog Owner
 
I certify by my signature that I have read and understand the Rolla Missouri Kennel Club’s Constitution and By-Laws and have signed the Code of Ethics of the Rolla Missouri Kennel Club and agree to abide by them.  I also certify that I am in good standing with the AKC and agree to abide by the AKC Rules and Regulations. 
(Endorsement of two club members required)

APPLICANT'S SIGNATURE ___________________________________  Date___________

MEMBER'S SIGNATURE ______________________________________  Date___________

MEMBER'S SIGNATURE ______________________________________  Date___________ 

SECRETARY'S USE ONLY

Date Application Received:  __________________

Code of Ethics Signed:  Yes  -  No

Read to Membership:    Yes  -  No

Voted in as Member:      Yes  -  No       Date:  ___________________

Dues Paid:                      Yes  -  No