NAME: _____________________________________________________________________________

ADDRESS: __________________________________________________________________________

CITY: _____________________ STATE: ____________  ZIP: __________________________________

COUNTRY: __________________________________________________________________________

Telephone/Fax/Internet Information

HOME PHONE: ______________________________________________________________________
CELL PHONE: _______________________________________________________________________
BUSINESS PHONE: ___________________________________________________________________
FAX NUMBER: _______________________________________________________________________

EMAIL ADDRESS: ____________________________________________________________________

WEBSITE NAME: _____________________________________________________________________
WEBSITE ADDRESS: __________________________________________________________________

Type of Membership Requested.....Make Checks payable to AHTCA
NEW/Renewal:  $20.00 (yearly)
Junior Membership:  $10.00 (yearly)
Address Change:  $10.00      
Breeder Referral Listing:  $25.00 (yearly)
Please check: Payment enclosed (     )      Payment submitted On Line (     )

Don't forget to print and sign a copy of the AHTCA Code of Ethics to enclose with this form.

I hereby apply for membership in the American Hunt Terrier Club Association.  I agree to abide by the
objectives and purposes stated in the AHTCA Constitution and By Laws.

Sign: _________________________________________  Date: _____________________________   

Home of the Hunt Terrier also known as the Black and Tan Jack Russell
AHTCA Membership Application
American Hunt Terrier Club Association
13288 Bean Rd.  Alexander, AR  72002
% Karen Adams
Phone: 501-607-4455    Email
Please use your browsers print button, fill out completely
and mail to the AHTCA