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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 $37.00 ( )Household $52.00 (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.
I/we agree to abide by the Constitution and By-Laws of the UBSDA, the rules and regulations of the United Kennel Club, and I/We understands that
full membership is contingent upon approval by the Board.
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:
Alleyne Dickens
144 – 6th Street
Colonial Beach, VA 22443
Received_____________________________________
Check # _____________________________________
Approved___________________________________
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