WORKING AUSSIES OF VA

Application for Membership

NEW MEMBER_____ Year______ RENEWAL_______ Year_____

Type of Membership: Single _____ Family ______ Junior _____

Name(s) ______________________________________________

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______________________________________________

Address: ______________________________________________

______________________________________________

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Phone: Home __________________ Cell __________________

Email Address: _________________________________________

ASCA Membership Number (if member) ____________________

Areas of Interest (Check all that apply):

_____ Conformation _____ Stockdog _____ Agility

_____ Obedience _____ Tracking _____ Other ______________

list

Any other pertinent information you would like to be considered in the review of your application: ______________________________________________________________________________________

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New Member Application Fee enclosed: $10.00

Dues enclosed: _________________

Single Membership is $24.00 per year.

Family Membership is $24.00 for first member, $12.00 each addit. member from same residence.

Junior Membership (under age 18) is $12.00. This is a non-voting membership.

Dues shall be pro-rated from July 1^st. Note – fees will be refunded if application is denied

Make checks payable to Working Aussies of VA and mail to: C. Lee Hussey, Treasurer

110 Sandpiper Drive

Portsmouth, VA 23704

By signing this application, I/we agree to abide by the Constitution, Bylaws, Rules, Regulations, Code of Ethics and Dispute rules of both ASCA and the Working Aussies of VA.

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Signature(s) Date

Date Received________________________________ Amount Received $____________________