ROYAL SCHIPPERKES CLUB

                                                                          KKUSH – URCSH Nr. OO1

 

 

                MEMBERSHIP APPLICATION FORM

 

 

Please print or fill in by hand in capitals

 

 

Name ………………………………………….. First name ………………………….

 

 

Street …………………………………………   Nr. ………………… Box …………..

 

 

City …………………………………………… Country ………………………………….

 

 

Telephone number …………………………….

 

 

E-Mail address ………………………………….

 

 

Web site address …………………………………

 

 

I apply for a membership of the Royal Schipperkes Club and I agree to abide by the Statutes and Regulations of the club.

 

I certify that I am not a member of a club which is not recognized by the  FCI (International Cynological Federation).

 

 

To-day I pay …………… €

 

 

Membership fee: 20 € (Regular member – first member of the family)

                             30 € (Foreign members)

                             10 € (Family member – other members of the family, same address)

 

 

  Bank account: BE14 0010 7919 1583 -

     IBAN & BIC: 14 0010 7919 1583 – GEBABEBB   
        

                                          Royal Schipperkes Club  

 

 

Send your completed form to: Mrs. Agnes POLLET

                                            Dorpsstraat 85 – B- 3550 Heusden-Zolder

 

Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

 

 

 

Date ………………               Signature …………………………………….