Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Fax

(###)

###

####

Are your Mi-Kis registered?

Yes

No

Are you a member of any other dog clubs, breed clubs, and/or registries?

Yes

No

Do you have a kennel? *

Yes, I am a breeder. *Please fill out kennel sponsors below

No, I am a pet owner.

No, I am a minor between 10 and 17 years of age.

I hereby apply to participate in the American Mi-Ki Club. I certify by my signature below that I have read and agree to honor and uphold the Code of Ethics of the American Mi-Ki Club, that I have read and will comply with the requirements of the American Mi-Ki Club and that all the information appearing on this application is correct. I understand that the American Mi-Ki Club Constitution, Bylaws and Code of Ethics set forth the procedures that will be followed for resolving any cause of action, controversy, claim or disciplinary action and agree to abide by all resulting decisions. The American Mi-Ki Club reserves the right to reject an application or revoke participation. Misrepresentation on this application may result in the loss of privileges for the individual signer. By typing your name below, you are confirming that the information you provided in this form is accurate. You also fully understand typing your name is the equivalent of a handwritten signature. *

Do you give your permission to list your contact information, name, kennel name, email address and phone number on the Membership List in the Members Only section of the AMC website? This contact information will not be accessible by the public, only to AMC members.

Yes, I give my permission to list my contact information on the Membership List in the Members Only section of the AMC website.

No, I do not give my permission to list my contact information on the Membership List in the Members Only section of the AMC website.

Date *

MM

DD

YYYY