Rip Van Wrinkle Basenji Club
Application for Membership
Date___________
Name/s &
Address as
it should appear on mailings:
Names/s:_______________________________________________
Street:__________________________________________________
City:________________________State:_______Zip:____________
Land
line Phone:______________________Cell Phone:_______________
Email
Address:_________________________
Home
Page:____________________________
Kennel
name, if any:_____________________________
Specific interests (obedience, agility, lure coursing, conformation, therapy dog, cuddling, etc.) __________________________________________________________________________________
Other
club memberships_______________________________________________________________
+
Dogs:
Name__________________________________Date of Birth___________
Name__________________________________Date
of Birth ___________
Name__________________________________Date
of Birth ___________
Name__________________________________Date
of Birth_____________ *Use reverse
side if needed
Dues are
$15 USA, $20 outside USA. Feel free to give only what you can.
+Dues for the year of July 1st, 2011 - July 1st,
2012:___________
+Raffle
tickets for:
1.
A 1954 hardcover edition, with original, clean, dustcover, of "Good-bye My
Lady," by James Street.
2.
A signed 1978 copy, with notes in the back, of "The Basenji Illustrated,"
by Robert W. Cole. 6 for
$10___________
+ Poster –
Lunetta-Kamen BHE Quilt Poster, $30:_____________
+ Poster – The BakersÕ Dozen, $30:_____________
+ Poster – Twin Towers
Tight Rope, $30:_____________
+Poster - Kiafrika Azima/Basenjis Ôn Da Hood,
$20:____________
+Poster - Kiafrika Azima
2/Babies Ôn Da Hood, $20:_________
+Contribution for equipment, Rescue
fund:___________
+Total:______________
Make checks
payable to the Rip Van Wrinkle Basenji Club.
Mail to:
Karen Sahulka, 205 Plochmann Lane,
Woodstock. NY 12498
Constitution, By-laws, Roster,
on request.
The Rip Van Wrinkler is
published quarterly.
rvwbasenjiclub.org