BRTCA Membership Application

BRTCA Membership Application

Applicant Sponsors

Disclaimer

BRTCA Membership Application

Please fill out the information below to apply to join the breed club.
Membership Types Explained

Regular membership - for individual U.S. Residents, 18 years and older.

Family membership - for two U.S. Residents of the same household, 18 years and older, and Juniors in household.

Foreign membership - for individuals residing outside of the U.S., 18 years and older.

Affiliate membership - for individual U.S. Residents, 18 years and older, without sponsors for regular membership.

Junior membership - for individuals between the ages of 8 years and 18 years of age.
Membership Type (Single: $30 annually - Family: $35 annually)
Full Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address

Confirmation EmailPlease enter your email again to verify.
Occupation
Additional Applicant Name

First NameLast Name
Email Address
example@example.com
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is Additional Applicant a Junior?
A junior is under 18 yrs old
Do you have a Junior family member you'd like to add?
Junior Applicant Name

First NameLast Name
Email Address
example@example.com
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is your parent or household family member a member of the BRTCA?
Please include the name of your parent or household family member.

Parent or Family Member First NameParent or Family Member Last Name
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you a Breeder?
Kennel Name:
How many Black Russian Terriers do you own?
How many Black Russian Terriers do you co-own?

Other Breeds Owned (if any)
Please separate breeds with a comma.
Do you belong to any other all-breed or specialty clubs?

Please check all areas of interest:

Other
Do you have any special skills or abilities you feel might be useful to the BRTCA? If so, please explain.
Would you be interested in serving on any of the following Committees? If yes, which one(s)?

Other
Briefly describe your experience or interest in the breed club
Applicant Sponsors

Each applicant must be sponsored by two members in good standing of the BRTCA who are not related to the applicant. Please provide the Name, Email Address and Phone number for two sponsors.
Sponsor #1

First NameLast Name
Phone Number (Sponsor #1)
Please enter a valid phone number for Sponsor #1.Format: (000) 000-0000.
Email (Sponsor #1)
Please enter a valid email address for Sponsor #1.
Sponsor #2

First NameLast Name
Phone Number (Sponsor #2)
Please enter a valid phone number for Sponsor #2.Format: (000) 000-0000.
Email (Sponsor #2)
Please enter a valid email address for Sponsor #2.
Applicant Signature
Additional Applicant Signature
Date

MonthDayYear
Date
Disclaimer

By clicking 'Submit Application', you are acknowledging and agreeing to abide by the BRTCA Constitution and Bylaws, Code of Ethics, and the rules and polices of the Black Russian Terrier Club of America and the American Kennel Club. Submission also constitutes agreement to receive club correspondence from the BRTCA via Email, Phone and Text Message (when applicable). You will receive a confirmation email upon Submission. Your sponsors will also receive an email upon submission that they must sign & approve before your application can be processed.
Applicant(s)
Should be Empty:

Rows	Club Name & Office Held (if any)
1
2
3
4
5

Registered Name

Registration Number

Breeder(s)