Name                                                                                                                     

Street Address                                                                                                   

City                                                                                                                        

State                                                                                                                      

Zip Code                                                                                                              

Daytime Phone                  (               )                                                               

Evening Phone                  (               )                                                               

E-Mail                                                                                                                     

Samoyeds owned-total                                                                                    

Boys (names)                                                                                                       

Girls (names)                                                                                                       

Dogs owned other than Samoyeds-total                                                   

List other breeds/names                                                                                  

Memberships-  Are you a member in good standing with any of the following?

(Check all that apply)  ___None  ___AKC  ___SCA  ___IKC  ___UKC  ___Breed Club

Other (list)                                                                                                                                                                                            

Events-  Have you ever participated, coached and/or judged any of the following?

(Check all that apply)  ___None  ___Agility  ___Conformation  ___Coursing  ___Herding  ___Obedience  ___Sledding  ___Tracking  ___Other (describe)                                                                                                                                                  

Judges-  Are you or any member of your immediate family a licensed judge?

___No  ___Yes   

If yes, please list events                                                                                                                                                                       

If yes, which association?                                                                                                                                                                   

Interests-  What activities are you interested in?  (Check all that apply)  __None 

___Agility  ___Breeding  ___Conformation  ___Coursing  ___Education  ___Herding ___Obedience  ___Sledding/Carting  ___Tracking ___ Other interests (please list)                                                                                                                                 

Talents-  Do you have any special talents/expertise/interest that might benefit the Club or its activities (i.e. web design, artwork, dog training, fundraising etc.)?  If yes, please describe                                                                                                  

Sanctions-  Have you ever been sanctioned and/or had other disciplinary action taken by the AKC, SCA, or any other governing body (including any local, state, or federal government agency) for any animal related reason?  If yes, please describe                                                                                                                                                                                                   

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