MPBA 2ND QUARTER 2020 FOR WEB

Membership & Renewal Form 2020 Membership & Renewal Form 2020 NAME: _______________________________________________________________ KENNEL NAME: ______________________________________________________ (If Applicable) ADDRESS: ___________________________________________________________ _____________________________________________________________________ ADDRESS: ___________________________________________________________ _____________________________________________________________________ NAME: _______________________________________________________________ KENN L NAME: (If Applicable)

Office Use Only: Paid Via: q Check #________ q CC q Cash Date:_____________ Office Use Only: Paid Via: heck #________ q CC q Cash Date:_____________

CITY: ___________________________________________ STATE: ___________ ZIP: __________________ PHONE: _______________________________________ CELL: ___________________________________ E-MAIL __________________________________________________________________________________ WEBSITE: ________________________________________________________________________________ CITY: ___________________________________________ STATE: ___________ ZIP: __________________ PHONE: _______________________________________ CELL: ___________________________________ E-MAIL __________________________________________________________________________________ WEBSITE: ________________________________________________________________________________ SPEC IAL SIGN UP NOW TO GET THE REST OF 2020 INCLUDED WITH YOUR 2021 MEMBERSHIP! Membership Dues are $40.00 Membership Dues are $40.00 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 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 All members will be included in Directory List in Directory q YES q NO Remember: Youth Memberships are FREE Membership Dues are $40.00 All members will be included in Directory List in Directory q YES q NO Remember: Youth Memberships are FREE

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

Rev. 02/2020

Rev. 02/2020

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