Owner/Lessee*:
Membership Number*:
Email Address*:
Cofirm your Email Address*:

Address (Number and Street)*:
Suburb*:
Post Code*:
Phone Number:

Dogs Registered Name:(full name including titles)*:
Date of Birth*:
Dog or Bitch*:

Breed*:
Dogs Registered Number*:
Handler (if different from owner):

Height at Shoulder (cm)*:
Agility Jumping Height:
Rally Jumping Height:
Obedience Jumping Height:

Bred By:

Sire:
Sire Reg No:

Dam:
Dam Reg No:

Are you currently a financial member of the Club*?


Other information that you wish the club to know: