WANT TO BE LISTED IN THE DIRECTORY? q YES q NO All members automatically included in directory unless otherwise specified
Membership Application/Renewal Form 2024 *PLEASE PRINT LEGIBLY. MPBA is comprised of members who volunteer their time for offices and services. MPBA will not be responsible for calling or emailing applicants to confirm what is written is correct if not legible.
Name Kennel Name Street Address City
State
Zip
Phone/Cell Email
Website Chapter Dog Breeds Raised (Please separate by comma)
PAYMENT INFORMATION
Membership Dues are $40.00
Youth Memberships are FREE!
Memberships are valid from March 1st to March 1st
If paying by check, please make out to Missouri Pet Breeders Association. Forms and checks may be mailed to: MPBA • 313 B West Commercial • Lebanon, MO 65536 Visit us online at www.mpbaonline.org
CREDIT CARD PAYMENTS If paying by credit card, please complete:
Office Use Only: Paid Via: q Check #________ q CC q Cash Date:_____________
Card # Exp. Date
/
CVV
38
Rev. 08/23
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