BCSA CURRENT MEMBERS ONLY -  RENEWAL FORM
 Maximize page for easier entry.  
 NEW MEMBERSHIP
  AFFILIATE CLUB RENEWAL

To renew your membership, enter your information in fields below and select the "print" option on your browser.  If you choose to hand print your renewal, please make certain all information is legible. 

  • Late fee: $10 (if renewing February 1 - March 31; members must reapply for membership after March 31)

  • A membership will be considered as lapsed and automatically terminated if such member’s dues remain unpaid 90 days after the first day of the fiscal year.

Date:
Member Name:
Applicant Name
(if household):
Age:  
Address:
City/State/Zip:

Best Telephone:
E-Mail:
Meeting Notices:
(check one)
YES Send BCSA meeting notifications via e-mail.
NO Send BCSA meeting notifications via US mail.
Enclosed:
Membership Type/Dues
 $		 Rescue Donation
 $		 Health Research Donation
 $
   
Applicant Signature: ____________________________________
PAYMENT - US MAIL: Mail your form with check payable to BCSA and send to: Kathy Sours - 3821 W. Charter
Oak Road - Peoria, IL 61615. Questions: E-mail Kathy or telephone 309.693.9331
PAYMENT - CREDIT CARD: Membership Shopping Cart

RENEWAL EXCEPTION:  Memberships for those joining after 11/1/10 do not expire until 12/31/11. No renewal is due at this time for these memberships.

MEMBERSHIP LAPSE/LATE FEE: Dues are payable on or before the last day of January each year. A late fee of $10 will apply for dues paid after the last day of January, but before the last day of March, of each year. If you allow your membership to lapse, you must reapply as a new member.

BREEDER REFERRAL: If you are currently on the Breeder Referral List (or would like to be), please complete the EZ On-Line Breeder Referral Form or attach a separate sheet of paper containing the following information (typed or legibly printed): name, address, phone, e-mail, website, health checks given (eyes, hearing, hips, elbows, thyroid, other), activities you do with your dogs (agility, conformation, flyball, freestyle, herding, obedience, rally, tracking).

Office Use Only: Received _______________________  Check #: _________  Amount: ___________

Form Rev. 02/03/2012