Membership Application

MEMBERSHIP APPLICATION  

OFFICERS:                 

President                      Bill Brown          

Vice President              Frank Petro

Secretary                     Rob Pogue

Treasurer                     Todd Rittko

Board Members:          Chuck Hagan

                                     Rick Doverspike

                                     Char Givens

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Date                                   _                                                      Phone                                  _

Name                                                              _                          Sponsor:   __________________

Street                                                                _                          E-mail Address:____________________

City                                                                    _

State    _         Zip Code                  _

Breed of Dog                              _                                               Number of Dogs                  _

Dog’s Level of Achievement:                                                        Owners Level of Handling:

Puppy               _.                                                                                 Novice              _.

Started             _.                                                                                Beginner           _

Intermediate / Seasoned    _.                                                              Moderate          _

Senior / Finished         _.                                                                     Experienced      _

I have received ____   or applied _____ for PA Child Abuse History Clearance.*

Type of Membership:                                            Amount Enclosed:

Individual                                                          $15.00          .

Family                                                              $25.00          .

Junior (under 18)                                               $ 5.00          .

Referred by                                                                     _

Please mail completed application and membership dues to:

Rob Pogue, Secretary

302 Buckingham Road

Pittsburgh, PA 15215

Make checks payable to:   SWPAHRC