Black Russian Terrier of New Jersey
Renewal Membership Form
Member(s) Name: ________________________________________________________
Address:_______________________________________________________________
City, ST, ZIP:___________________________________________________________
Renewal Membership Dues:
Black Russian Terrier Club of New Jersey dues are due now for the membership year of 20___ . Any dues received after March 1st, 20___ is a lapse in membership and would need to reapply.
Please get your dues in before March 1st, 20____ to avoid lapse in membership
Dues are as follows:
Individual Membership - $25.00 U.S. Funds per year - open to any owner 18 years or older
Family Membership - $30.00 U.S. Funds per year family member over 18 years of age with two votes
Associates Membership - $25.00 U. S. Funds per year open to non owners No voting rights
Please make check payable to Black Russian Terrier Club of New Jersey
Please make any corrections to keep your information updated, sign & return form with payment to Vincent Modica
Trophy Donation: $___________
Membership Fee Enclosed $ Individual ( ) Family ( ) Associates ( ) (please check one)
Total amount enclosed: $_____________
If Family Membership Please list other members for Family membership:
Name:
Home Phone #:
Fax #:
Kennel Name:
Email:
Website:
Do you still own a registered Black Russian Terrier: YES ( ) NO( ) How Many?______
If yes, what is the registered name of your dog?:
Do you approve of your contact information being posted on: Website: Yes ( ) No ( ) Newsletter: Yes ( ) No ( )
Any Publication: Yes ( ) No ( ) (please check)
I/We agree to abide by the By-laws as adopted by the Black Russian Terrier Club of NewJersey. and that all the above information is accurate to the best of my knowledge.
Please mail renewal application and dues to:
Jennifer Modica
175 Stagecoach Road
Cape May Court House, NJ 08210
Black Russian Terrier Club of New Jersey - Thanks you for your support!