Address:__________________________________________________________________

City:____________________________State:_________________Zip:_________________

Phone:____________________ Email:__________________________________________

Check One: Renewal____________ New Application_____________

Main Interest(s) Relative to the Australian Shepherd

___Breed, sell and promote the breed
___Obedience
___Herding
___Agility
___Conformation
___Tracking
___Other____________________________

Is/are your dog(s) registered with the Australian Shepherd Club of America?_____Yes _____No
Other Registry? (Please Specify)________________________________________________
Are you a member of the Australian Shepherd Club of America? _________Yes ________No
If so, please give your (not your dog's) ASCA membership number:_____________________

Membership: Please check one. All memberships recieve flyers and a subscription to our newsletter,
The Aussie Fan.

_____Dual couple or parents and/or minor child (2 votes)$20.00
_____Single-one adult (1 vote)$15.00
_____Junior-one child 10-17 years of age, non-voting $3.00
_____Aussie Fan Subsciption only (one per household), non-voting $10.00

WE, the undersigned, do submit this application for membership in FASA and hereby agree to abide
by its Constitution and By-Laws.

Signature:____________________________________Date:___________________

Signature:____________________________________Date:___________________

Mail checks, payable to FASA to Lynn De La Torre, 9121 94th Ave. N. Seminole, FL 33777
email: lynn_bd@yahoo.com