ASA Membership Application Form ASA Membership Application Form This is a form for submitting a new application to the ASA for membership.Date* MM DD YYYY Name* First Last Spouse or Partner's Name First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred Phone for Contact*Email* Do you hope to breed or be a stud owner?*Will you exhibit or train your Stabyhoun for:*ObedienceRallyAgilityHuntingTherapy WorkScenting/ Barn HuntConformationAre you a licensed Judge? If so, what organization?Other dog clubs to which you belong and offices held:The Ameri-Can Stabyhoun Association has no paid staff and is run entirely by member volunteers. If accepted for membership in the ASA, I would be willing to volunteer:* Yes No Perhaps occassionally My special interest and skills are:Would you like your contact information to appear in the “Membership Directory” which appears in the “Members Only” section of the ASA website? It will assist other Staby owners close by to get in touch with you for gatherings and play dates! Please indicate:* YES No Your Stabyhoun InfoIf you do not yet own a Staby, please leave this blank and send the information below to the ASA Membership Chairman when you have received your pedigrees, etc. If you have more Stabyhouns, please notify us separately.Dog 1 - Registered NameCall nameDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Microchip or Tattoo Number of DogSex of Dog Male Intact Male Neutered Female Intact Female Spayed Color of Dog Black/ White Black Roan Brown/ White Tri-Color Breeder's NameAKC Registration NumberFCPR Registration NumberForeign Registration NumberSire Name and Registration NumberDam Name and Registration NumberIf more than one Staby, please send us the information in an email to: Membership@stabyhouns.org. Thank you.I hereby apply to the Ameri-Can Stabyhoun Association for membership, and by "signing" this application agree to abide by the ASA Constitution, Bylaws and Code of Ethics found on the ASA website (www.stabyhouns.org). Please check the box..* I agree to the above statement.Choice of term for membership*Three yearsOne YearPayment Method*PayPal CheckoutCredit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Membership year runs from July 1 to June 30st. All memberships approved on or after April 1 will be applied for the balance of the current and the following year. You will be redirected to the PayPal site to pay. If you prefer to send the ASA a check, the address is below: Ameri-Can Stabyhoun Association c/o Gail Brown, Treasurer 344 JB Leonard Road Castalia, NC 27816 PLEASE NOTE THAT MEMBERSHIP IS NOT AUTOMATIC AND IS DETERMINED AT THE DISCRETION OF THE BOARD. If for any reason your membership application is denied, we will refund your application fee.
