Mixed Breed Dog Club Logo

Membership Application

Please consider a $10 donation for the first dog, and $5 for each additional dog to Phyllis Massa-Busch at 416 Kimberly Lane, St. Peters, MO 63376-4009. Please make checks out to MBDCSTL. Membership dues are renewable in August, every year. If you have more than 2 dogs, please fill out the form again, after submitting.

Personal Information:
First Name:         
Last Name:         
Address 1:         
Address 2:         
City:         
State:         
Zip:         
Phone:         
Cell:         
Email:         

Dog 1 Information:
Dog Name:         
Birth Date (MM/DD/YY):         
Shoulder Height:         
Breed:         
Titles:         
Altered:          Yes   No
Proof of Altered:         
Dog Picture:         

Dog 2 Information:
Dog Name:         
Birth Date (MM/DD/YY):         
Shoulder Height:         
Breed:         
Titles:         
Altered:          Yes   No
Proof of Altered:         
Dog Picture:         

Dog Club Servey:

Like To Help By:

Community Demos:   Yes No   ||   Committee Member:   Yes No
Committee Officer:   Yes No   ||   Photography:   Yes No
Therapy:   Yes No   ||   Public Relations:   Yes No
Shows:   Yes No   ||   Other:   Yes No
               

Attending Christmas Party?
Yes   No


By pressing Submit, I certify that the infomation given is complete, I read and agree to abide by the Code of Ethics.

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