Date ____________________________

Name __________________________________________________________________

Address ______________________________________________________________________

________________________________________________________________________

Phone _____________________________ Email address _________________________

Occupation ______________________________________________________________

Other Club Affiliations_____________________________________________________

Name of Clumber(s) you have: ______________________________________________

Name of your clumber website: ______________________________________________

I agree to abide by the constitution and by-laws of the Williana Clumber Spaniel Club, by the rules and regulations of the American Kennel Club, and to support WCSC activities. I certify that I am currently in good standing with the AKC.

Signed___________________________________________________

Signed ___________________________________________________

Sponsor signed_______________________________ Print Name___________________

Sponsor signed ______________________________ Print Name ___________________

**must be signed by two sponsors from Williana**

Check Type of Membership Desired:

$25.00 per person Individual membership fee due with completed form.

(This gives you voting privileges)

$15.00 per person Associate membership fee due with completed form

(Not eligible to vote or hold office)

Return completed form with fee to: Williana Clumber Spaniel Club

Susan Rogers, Secretary

701 Diving Hawk Trail

Madison, WI 53713