E-Mail:

Name:

Street Address: City: State:

ZipCode:

Occupation:

Phone Number: Day Evening Cell

Are you a Breeder? Yes No

Are you an Exhibitor? Yes No

Are you a Pet Owner? Yes No

Are you a Groomer? Yes No

Are you a Handler? Yes No

How many Chihuahuas do you own now?

Are all your dogs registered with AKC? Yes No

If not how many are? How many are not?

Are you in good standing with the American Kennel Club? Yes No

Have you ever been suspended by the AKC? Yes No

If so when?

If so , how long were you suspended?

If so, for what reason were you suspended?

Have you ever been suspended or denied membership in any recognized AKC Club?

If so, please explain:

Do you have membership to any other dog club(s)?

If so please list:

While a member did you ever hold an office, served on the board or sit on a committee?

If so please list:

Do you plan on being a working member of this club? Yes No

Please select which of the committees you would like to serve on: Hospitality Trophies Show Grounds Transportation Public Relations

Are you approved to judge any particular breed?

If so, what breeds?

How many other breeds do you own?

If so how many of each breed?

Did you purchase your Chihuahua from a breeder? Yes No

If so, whom:

Have you ever attended a dog show? Yes No

If so, approximately how many times?

Have you ever bred a litter of puppies? Yes No

If so, how many?

Did you sell the puppies? Yes No

Name of your two sponsors: 1 2