I wish to become a member of the BASENJI CLUB OF SOUTHEASTERN WISCONSIN, INC. I submit dues for $7.00 for a Single membership; $12.00 for a Household membership plus $1.00 for each Junior membership (under 18) in conjunction with another adult household member; or $3.00 for an Individual Junior membership not in conjunction with a household member. (Complete name and age of Junior members)  A Household membership is defined as two persons residing at the same address, each holding individual voting privileges. Junior members do not carry voting privileges.

Under acceptance as a member, I hereby agree to abide by the Constitution and By-laws of the BASENJI CLUB OF SOUTHEASTERN WISCONSIN, INC. that may be in effect at any time. I hereby attest that I am a member in good standing with the American Kennel Club and that I agree to abide by the Constitution and By-Laws of the Basenji Club of America, Inc. that may be in effect at any time.

       Name of First Applicant:

Name

        Name of Second Applicant:

Name

        Date:  

        Please provide the following contact information:

Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Phone
FAX
E-mail

        Junior Membership Information:

Junior Member

        Age 
       

Junior Member #2

        Age 
   

Junior Member #3

        Age 

       Kennel Name, if any:

Kennel Name

       Kennel Name registered with AKC?  Yes No

        Other Club Affiliations (All-breed, Training, Other breeds):

        Offices or Positions held in other clubs:

        Specific interests (obedience, committee work, field trials, agility, therapy):

        Check any areas of our Rescue Program you have an interest in serving:

 Foster Care     Transport     Fund Raising     Public Relations

        Do you have or plan to have for sale:

Puppies    Adults   Stud Service