NAME(S): ______________________________
E-MAIL ________________________________
ADDRESS: ______________________________
CITY/ZIP ______________________________
TELEPHONE (day) ______________________________
TELEPHONE (night)______________________________
1. DOG'S NAME: ______________________ BREED: __________
COLOR: __________ MALE/FEMALE SPAYED/NEUTERED: Y/N
2. DOG'S NAME: ______________________ BREED: __________
COLOR: __________ MALE/FEMALE SPAYED/NEUTERED: Y/N
3. DOG'S NAME: ______________________ BREED: __________
COLOR: __________ MALE/FEMALE SPAYED/NEUTERED: Y/N
SIGNATURE: _________________________________________ DATE: _______________
NEW GROUP MEMBER? Y/N
DO YOU CURRENTLY HAVE A PERMIT FOR THE BECK LAKE DFA? Y/N
MEMBERSHIP FEE: $10.00 per year
RETURN TO: BECK LAKE DOG AREA GROUP
C/O GIA HEYBROCK
8939 A. ROBIN DR., DES PLAINES, IL 60016
Phone: 847-635-7024, Fax: 847-635-8804, E-mail: beckdogs@att.net