Name:       __________________________________ Phone: __________________________ 

Address:    __________________________________ E-Mail: _________________________ 

City:       __________________________________ State: _____ Zip Code: __________

Dog's Name: __________________________________ Breed: __________________________

Dog's Name: __________________________________ Breed: __________________________

Dog's Name: __________________________________ Breed: __________________________

I am interested in the following club events
      [ ] Annual Banquet    [ ] Winter Hunt       [ ] Fun Run           
      [ ] AKC Field Trials  [ ] AKC Hunt Tests    [ ] American Field Trials
      [ ] Game Fair         [ ] Training Sessions [ ] Other __________________

Membership Type (check one)
[ ] I am enclosing $30.00 dues for a "Full" membership, which
    includes a subscription to the American Brittany magazine.

[ ] I am enclosing $15.00 dues for an "Associate" membership,
    which does NOT include a subscription to the American Brittany magazine.

[ ] I am enclosing $5.00 dues for an additional family member.

Print this page out and mail to:
St. Croix Valley Brittany Club, 8764 Norwood Lane, Maple Grove, MN 55369