Lake Erie Irish Water Spaniel Club

Membership Application

NAME: ________________________________________________________ DATE:____________________

ADDRESS:________________________________________________________________________________

CITY:__________________________________________STATE:_______________ZIP:________________

DAY PHONE:________________________________EVENING PHONE:______________________________

E-MAIL ADDRESS:___________________________________________________________________________

KENNEL NAME: ________________________________________ OCCUPATION: ____________________

TYPE OF MEMBERSHIP:

□ FAMILY ($25.00) □ INDIVIDUAL ($15.00) □ YOUTH ($5.00) (Under 21 years old, non-voting)

IS THIS A □ NEW MEMBERSHIP? □ RENEWAL? (Payable by March 1)

REGISTERED NAME OF IWS (including all titles): (Use back of this sheet for all additional dogs you own.)

___________________________________________________________________________________

CALL NAME:_________________________SEX:__________BIRTHDATE:___________________

SIRE:______________________________________________________________

DAM:______________________________________________________________

AREAS OF INTEREST: □ Conformation □ Obedience □ Rally Obedience □ Tracking □ Field Events □ Agility □ Breeding □ Family Dog □ Hunting

□ Other________________________________________________________________________

HAVE YOU: (AKC requires this information for new Club approval)

□ Registered a litter with the AKC within the past 3 years? □ Handled an IWS in an AKC licensed event within the past 2 years? □ Earned a title (Please specify) _______________ □ Are you an AKC licensed judge?

NAMES OF 2 MEMBERS WHO ARE WILLING TO SPONSOR YOU. (Required after January 1, 2006):

(1) ___________________________________________ (2) __________________________________________

Make checks payable to: Lake Erie Irish Water Spaniel Club (or LEIWSC)

Mail to Secretary: Kathy Dingledy 5784 East Main Road, Brocton, NY 14716