Name:                         Phone:              

Address:                          Fax:    

City:                  State or Province:                  Zip: 

Occupation:             Email Address:              

Registered Kennel Name (if any): 

Website address (if any): 

Please list two references that we can contact.  One MUST be an SSDCA Inc member in good standing.

Name:                     Contact (phone # or email):              

Name:                     Contact (phone # or email):              

Are you now or have you been a member of any other clubs?

Club Name:     Type of Club: 

Member from:              to                 Did you hold any office?  (if yes, give office) 

Please list any additional club affiliations/positions held at the end of this form

If asked, would you be willing to function in any particular office or on any committee, or is there any service to the club that you would like to perform?  Please detail:

How many Shiloh Shepherds do you own?    Are they: Show Quality Breed Quality Working Pet Quality

Please list the name(s) of your Shiloh Shepherd(s) and the breeder(s)

If you would like to tell us more about your dogs, your breeder, etc, please use the area at the end of this form.

Do you plan on purchasing another Shiloh Shepherd in the future?        Yes  No   When? 

What are the exact requirements for the dog you will purchase next?

Do you plan on showing your dog if he/she meets all the quality requirements? 

Please state your past experience in dog showing/training below

What other plans do you have for the Shilohs you now own/plan to acquire in the near future? (Please select all that apply)   Obedience Therapy Service Dog Search and Rescue Agility Police Work Schutzhund Herding Companion Tracking (hold down the control key to make multiple selections)

A short statement as to why you would like to become a member would be appreciated:

A short statement as to what you expect from/what you can do for our club would be appreciated:

Additional comments or explanations of previous items:

Please select method of payment below.  Choosing PayPal will open a new browser window.  Please remember that your SSDCA Inc reference will be contacted prior to application processing;

PayPal payments should be made out to:  SSDCABoard@aol.com

Initial dues are 1 year - $35  2 years - $55  3 years - $75

I am making payment via:

Check    or   PayPal

My submitting this form I agree to abide by the Constitution and the By-laws of the SSDCA Inc and if applicable, the Breeders Code of Ethics.  All the information given above is correct to the best of my knowledge.  I understand any fraudulent statements made herein could lead to the revocation of my eligibility. I have read the SSDCA Constitution   Yes No

THANK YOU for your interest.  You will receive an email regarding your application in a few days.