YTCA Members Name______________________________________________
 

Address _________________________________________________________
 

City ___________________State ______ Zip ______________
 

Telephone __________________________ email ________________________
 

Date voted into membership: ____________________________________________
 

Owner of ROM applicant: _____________________________________________
 

Breeder of ROM Applicant: ____________________________________________
 

AKC registered name and number of ROM applicant:
 

Name _______________________________No._______________Sex ________
 

AKC Names and numbers of Champion get (6) or produce (3). All get or produce must
have verification documents submitted with this application.
 

Note: If original documents are sent, you must provide a stamped self-addressed
envelope to have them returned.
 

AKC Registered Name AKC Number
 

1. _______________________________________________________________
 

2. _______________________________________________________________
 

3. ________________________________________________________________
 

4. ________________________________________________________________
 

5. ________________________________________________________________
 

6. ________________________________________________________________
 

I certify that this application and enclosed material is true and correct to the best of my
knowledge and belief.
 

YTCA Members Signature_______________________ Date __________ 20_____
 

Application verified by___________________________ Date __________ 20_____
 

ROM # ______________________________