BCSA: Membership Application

APPLICANT INFORMATION

First Name:

(R)

Last Name:

(R)

Household Name:

(R) Enter N/A if Individual Membership.

Age:

(R)

Address:

(R)

City/State/Zip:

(R)

Best Telephone:

(R)

E-mail:

(R)

Note:

Members with an e-mail address will receive the annual Membership Roster via e-mail. Make certain we are notified if your e-mail address changes. Enter N/A to have the Roster mailed.

Sponsor's Name:

(R)

Note:

Membership applications will not be processed unless a sponsor name is listed and your sponsor completes the Sponsor Form.

MEMBERSHIP INFORMATION

Membership Type/Dues:

(R)

Meeting Notices:

(R)

Agreement:

(R)

By selecting "AGREE", I agree to comply with the Code of Ethics, to support the Constitution and Bylaws and to strive to fulfill the Mission and Vision of the Border Collie Society of America.

Applicant's Signature:

(R)

By selecting "YES", I confirm that it has the same effect of my personal signature.

Household Signature:

(R)

Select N/A if Individual Membership. Household Membership: By selecting "YES", I confirm that it has the same effect of my personal signature.

Payment Method:

(R)

Credit Card Name:

Enter name on credit card if different from member name.

APPLICANT PROFILE (Please provide the following information to help us get to know you better.)

CANINE INFORMATION

Breeds Owned:

(R)

Border Collies:

Number of years in Border Collies:	(R)
Current number of Border Collies:	(R)
Border Collie litters bred in last three years:	(R)

BC Rescue:

List the Border Collie rescue organization in which you are a member, or enter N/A.
(R)

Areas of Interest:

Areas of Interest (Agility, conformation, herding, obedience, etc. - list all that apply.)
(R)

Titles

Titles (List highest title in each category which you have earned and number of titles at that level, UDX5 for example.)
(R)

Year Last Competed:

AKC Event:	(R)
Any Canine Event:	(R)

PERSONAL INFORMATION

Occupation:

(R)

Special Skills:

(R)

Club Activity:

List areas of Club related activity in which you would like to become involved.
(R)

Committees:

List Committees on which you would like to serve.
(R)

Approved Judge:

If you are an approved judge for any canine activity, list which activity and organization (ex, Herding/AKC), or enter N/A.
(R)

Note:

Enter any special notes needed.

	Complete the form below to apply for BCSA Membership. Your sponsor must complete either the eSponsor Form or the mail-in Sponsor Form. Review all information carefully before pressing "Submit Application". (R) = Required Information