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(Required field are marked with an ( * ))
* First Name: * Last Name:
Partner's First Name: Partner's Last Name:
* Address:
* City: * State:
* Zip: - * Phone: () -
* EMail:
Kennel Name:
Do you own a Shiloh?
 Yes   No 
If yes, please indicate quantity:
Dog(s):   Bitch(es):  
Registered Name: Date of Birth:
Sire: Dam:
Registered Name: Date of Birth:
Sire: Dam:
Registered Name: Date of Birth:
Sire: Dam:
Do you plan on purchasing
another Shiloh in the future?
 Yes   No 
Do you plan on showing/breeding your Shiloh if
he/she has all the quality requirements?
 Yes   No 
What other activities do you participate in with your Shiloh? (check all that apply)
Agility     Flyball     Search & Rescue     Therapy     Obedience:
Schutzhund     Herding     Other:  
Please state your past experience in showing/breeding:
* SSDCA Membership #: (All SSDCA-MAC members must be members of the parent club.)
By submitting this form with the membership fee below, I agree to abide by the constitution and by-laws of the SSDCA and, if a breeder, the Breeder’s Code of Ethics.  All the information given above is correct to the best of my knowledge
Individual ($15.76)
Partner ($10.61)

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