Membership Application/Renewal Form 2023
Office Use Only: Paid Via: q Check #________ q CC q Cash Date:_____________
NAME: ________________________________________________________________ KENNEL NAME: ________________________________________________________ (If Applicable) ADDRESS: _____________________________________________________________ ______________________________________________________________________
CITY: ____________________________________________ STATE: ___________ ZIP: ___________________ PHONE: ________________________________________ CELL: ____________________________________ E-MAIL ___________________________________________________________________________________ WEBSITE: _________________________________________________________________________________
Membership Dues are $40.00
List in Directory q YES q NO All members are automatically included in the directory unless otherwise specified *Remember: Youth Memberships are FREE *
If Paying by Credit Card, please complete: # ________________________________________________ Exp. Date: _______/_______ CVV :____________
CHAPTER: _________________________________________________________________________________
DOG BREEDS RAISED (Please separate by commas) : __________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 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. Memberships are valid from March 1st to March 1st Forms may be mailed to: Missouri Pet Breeders Association 313 B West Commercial • Lebanon, MO 65536 www.mpbaonline.org Rev. 10/22
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