Name:       Address:  

City:          Province:  

Postal Code:       Kennel Name:  

Email Address:       Phone Number:  

Please answer the following questions. Please note we are asking these questions in order to identify the interests and activities
important to our members mainly to assist in planning Chapter events.

Do you currently own an ISSR Shiloh? yes  no       If yes, please indicate number:   DOG     BITCH  

Registered Name:     Date of Birth:  

Sire:      Dam:  

Registered Name:     Date of Birth:  

Sire:      Dam:  

From whom did you purchase your Shiloh?  

Do you plan to purchase an ISSR Shiloh in the future?   yes   no

Do you plan on on showing/breeding your Shiloh if he/she has all the quality requirements?   yes   no

What other activities do you currently participate in with your Shiloh?  

Agility   Flyball   Search and Rescue   Obedience   Novice   Open   Utility   Therapy   Schutzhund   Herding

other - please describe:  

What activities would you be interested in trying with your Shiloh?  

Please list any other dogs/pets currently owned:  

All SSDCA-OC members must be members of the Parent Club, the Shiloh Shepherd Dog Club of America, Inc.

Please provide your SSDCA Membership Number and list any other Chapters to which you belong:  

If asked, would you be willing to function in any particular office or any committee?   yes   no

Is there any service for the Chapter that you would like to perform?  

I agree to abide by the Constitution and by-laws of the SSDCA, the Breeders Code of Ethics, and the Chapter's Policies and Procedures Handbook. All the information given above is correct to the best of my knowledge.

Applicant's name:      Date:  

Type of Membership   Individual $10.00   Family $20.00    New Member    Renewal

Total Payment sent by PayPal  

**Please return to the SSDCA-OC Membership Page to submit your payment through PayPal