MPBA 2ND QTR 2021 FOR WEB

Membership & Renewal Form 2021

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

All members will be included in Directory List in Directory q YES q NO Remember: Youth Memberships are FREE

If Paying by Credit Card, please complete: # ________________________________________________ Exp. Date: _______________ CVS :____________ CHAPTER: _______________________________________________________________________________ DOG BREEDS RAISED (Please separate by commas): ___________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ __________________________________________________________________________________________ PLEASE PRINT LEGIBLY. MPBA IS COMPRISED OF MEMBERS WHO VOLUNTEER THEIR TIME FOR OFFICES AND SERVICES. MPBAWILL NOT BE RESPONSIBLE FOR CALLING OR EMAILING APPLICANTS TO CONFIRM WHAT IS WRITTEN IS CORRECT IF NOT LEGIBLE. Memberships are valid from January 1st to December 31st

Mail to: Missouri Pet Breeders Association c/o Lynn Sartin, Membership Secretary 11751 Hwy M • Granby, MO 64844 www.mpbaonline.org

Rev. 01/2021

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