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United Belgian Shepherd Dog Association, Inc. ••• Membership Application
Name (s)
____________________________________________________________________________________
Address _______________________________________________ City _________________________
State ________________________________ Zip code ______________________
Country ____________________ Phone ________________________________
Email address ______________________________________________________________
Website address ____________________________________________________________
Varieties owned (please circle) G L M T Kennel name ______________________________
Areas of interest (Circle): Agility Conformation Fly ball Freestyle Herding Obedience
Ring Sport/Mondioring Schutzhund/IPO Tracking Weight Pull
Other:
__________________________________________________________
In what way(s) would you like to assist the UBSDA?
___________________________________________________________________________________
Are you a member of a local BSD club? ( ) Yes ( ) No
Are you interested in joining/organizing an UBSDA chartered Local BSD club in your area? ( )Yes ( ) No
Are you a breeder? ( ) Yes ( ) No ( ) Not Yet
Briefly describe your experience with Belgian Shepherd Dogs and dog activities on the back of this form.
Include number and breeds of dogs owned, litters produced, titles earned, judging experience, club affiliations and
offices held, years of experience, articles/books written, classes taught, etc.
UBSDA Membership Dues. Initial application /dues received after October 1 of any calendar year will be credited
with having paid their dues to December 31st of the following calendar year. Otherwise dues are due before
January 1 of each year.
Check one: ( )Single $30.00 ( )Household $45.00 (2 votes, 1 newsletter) ( )Junior $15.00
( ) First class option for Beacon. Add $15.00.
Applicants residing outside of the United States --- enclose an additional $15.00 for postage. All moneys must be
payable in US funds.
Applicant’s signature _________________________________________________ Date _____________
2nd Applicant’s signature ______________________________________________Date _____________
Two Sponsors’ Names (printed) and Signatures (sponsor must be UBSDA member for at least one year, sponsors
cannot live in same household or in household as applicant.
__________________________________________________________ Date ____________________
__________________________________________________________ Date ____________________
Applicant (s) name (s) will be published in the next newsletter. Letters from the membership regarding the
application will be accepted for 60 days after scheduled publication date. If no substantiated reason for denial is
present to the Board during that time, the application will be voted on by the Board.
If applicant is a Junior (11 through 17 years) application must have written consent of at least one parent or legal guardian
submitted with application. Juniors must supply birth date with application.
Send completed Membership Application form and check payable to:
UBSDA (in US funds)
Send to:
Cindy Fellows
UBSDA Corresponding Secretary
CMR 443 Box 88,
APO AE, NY, 09096-0088.
***************************************************************************************************************************************
Received_____________________________________
Check # _____________________________________
Name (s)
____________________________________________________________________________________
Address _______________________________________________ City _________________________
State ________________________________ Zip code ______________________
Country ____________________ Phone ________________________________
Email address ______________________________________________________________
Website address ____________________________________________________________
Varieties owned (please circle) G L M T Kennel name ______________________________
Areas of interest (Circle): Agility Conformation Fly ball Freestyle Herding Obedience
Ring Sport/Mondioring Schutzhund/IPO Tracking Weight Pull
Other:
__________________________________________________________
In what way(s) would you like to assist the UBSDA?
___________________________________________________________________________________
Are you a member of a local BSD club? ( ) Yes ( ) No
Are you interested in joining/organizing an UBSDA chartered Local BSD club in your area? ( )Yes ( ) No
Are you a breeder? ( ) Yes ( ) No ( ) Not Yet
Briefly describe your experience with Belgian Shepherd Dogs and dog activities on the back of this form.
Include number and breeds of dogs owned, litters produced, titles earned, judging experience, club affiliations and
offices held, years of experience, articles/books written, classes taught, etc.
UBSDA Membership Dues. Initial application /dues received after October 1 of any calendar year will be credited
with having paid their dues to December 31st of the following calendar year. Otherwise dues are due before
January 1 of each year.
Check one: ( )Single $30.00 ( )Household $45.00 (2 votes, 1 newsletter) ( )Junior $15.00
( ) First class option for Beacon. Add $15.00.
Applicants residing outside of the United States --- enclose an additional $15.00 for postage. All moneys must be
payable in US funds.
Applicant’s signature _________________________________________________ Date _____________
2nd Applicant’s signature ______________________________________________Date _____________
Two Sponsors’ Names (printed) and Signatures (sponsor must be UBSDA member for at least one year, sponsors
cannot live in same household or in household as applicant.
__________________________________________________________ Date ____________________
__________________________________________________________ Date ____________________
Applicant (s) name (s) will be published in the next newsletter. Letters from the membership regarding the
application will be accepted for 60 days after scheduled publication date. If no substantiated reason for denial is
present to the Board during that time, the application will be voted on by the Board.
If applicant is a Junior (11 through 17 years) application must have written consent of at least one parent or legal guardian
submitted with application. Juniors must supply birth date with application.
Send completed Membership Application form and check payable to:
UBSDA (in US funds)
Send to:
Cindy Fellows
UBSDA Corresponding Secretary
CMR 443 Box 88,
APO AE, NY, 09096-0088.
***************************************************************************************************************************************
Received_____________________________________
Check # _____________________________________
| Send completed Membership Application form and check payable to UBSDA in US funds to: Cindy Fellows UBSDA Corresponding Secretary CMR 443 Box 88, APO AE, NY, 09096-0088. |
| Send completed Membership Application form and check payable to UBSDA in US funds to: Cindy Fellows UBSDA Corresponding Secretary CMR 443 Box 88, APO AE, NY, 09096-0088. |