We know there are a lot of questions in this form - there are no right or wrong answers. Please completely answer ALL questions as it helps us to get a better idea of the best way in which we can help you.

First Name
Last Name
Kennel Name (if applicable)
Birthday	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:
Address
City
State	Please Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SD SC TN TX UT VA VT WA WI WV WY Other
Zip
Telephone
Cell Phone
Fax
Email Address
Website Address
Main breed of dog that you raise # of Females / # of Males
Second breed of dog that you raise # of Females / # of Males
Third breed of dog that you raise # of Females / # of Males
How long have you been raising dogs?
How do you usually find new homes for your puppies?	Please Select Paid Online Classified Ads AKC Online Classified Ads Free Online Ads Already have prospective homes before pups are born
Are your dogs registered?	Please Select No Yes - with AKC Yes - with CKC Yes - with other organization
Do you micro chip your puppies before they leave your premises?	Please Select Yes No
Do you micro chip your puppies yourself or does your Veterinarian?	Please Select I do them myself My veterinarian does it
Do you immunize your puppies yourself or does your Veterinarian?	Please Select I do them myself My veterinarian does it
Have you ever had a kennel inspection?	Please Select Yes No
If Yes by whom?
If Yes when? (MM/YYYY)
How are your adult dogs housed?	Please Select My dogs are in the house with me My dogs are in outside well maintained kennels My dogs are both inside and outside
How are your puppies housed?	Please Select My pups are in the house with me My pups are in outside well maintained kennels My pups are both inside and outside
Referred By: Please enter the name, kennel name or email address of the person that referred you
Level of Yearly Membership Required	Please Select Silver - $45 - 1 breed Gold - $55 - 2 breeds Platinum - $65 - 3 breeds
How would you like to pay for your membership?	Please Select Online by Credit Card I will mail a check