WANT TO BE LISTED IN THE DIRECTORY? q YES q NO All members automatically included in directory unless otherwise specified
Membership Application/Renewal Form 2025 *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.
DIRECTORY INFO Certain directory info is optional. Please specify your choices below.
MEMBERSHIP INFORMATION (*Required information)
* Name
Automatically Listed
Automatically Listed
Kennel Name (if applicable)
* Street Address
q YES
q NO
* City
q YES
q NO
* State
* Zip
q YES
q NO
* Phone/Cell
q YES
q NO
q YES
q NO
q YES
q NO
Website
Not Applicable
Chapter
Dog Breeds Raised (Please separate by comma; please specify toy, mini, or standard if applicable)
Automatically Listed
PAYMENT INFORMATION
Membership Dues are $40.00
Youth Memberships are FREE!
Memberships are valid from March 1st to March 1st Please make checks out to Missouri Pet Breeders Association, mailed to 313 B West Commercial • Lebanon, MO 65536 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
Visit us online at www.mpbaonline.org
Rev. 05/25
Missouri Pet Breeders Association | Page 28
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