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Egoli Nordic Spitz & Primitive Breeds Club

Membership Application/Renewal 

PLEASE PRINT THIS FORM  
(rightclick on this page & select print)
FILL IT IN AND FAX OR EMAIL IT TO  THE 
FOLLOWING ADDRESS TOGETHER WITH 
YOUR PROOF OR PAYMENT:

The Secretary -
Egoli Nordic Spitz & Primitive Breeds Club
tel:  074 101 0176
fax: 086 693 4486
e-mail Cheryl here...

Membership fee for Southern Africa:
Single R30 for 12 months;  Family R50 for 12 months
(includes free listing on website!)

Banking Details:
Egoli Nordic Spitz & Primitive Breeds Club
Nedbank - Isando 
Branch Code - 196 142 
Account Number - 196 1372 665 
Reference - your surname please

Payment by EFT or direct deposit preferred,
please fax through proof of deposit 
together with this form to
011 972 5452

 I/We hereby wish to apply for membership of the Egoli Nordic Spitz & Primitive Breeds Club
 and agree to abide by its Constitution and adhere to its Code of Ethics.

First Name:       Mr / Mrs / Ms / Family

Last Name:

Breeds Owned:

Postal Address:

E-Mail Address:

Telephone Number:

Cellular:

Facsimile Number:

Payment Method:                 Cash ........                     Cheque ...........                Direct Deposit .........

Family Members Names:  

Signature: ......................................................

Date: .......................................................

Approved:                                   Chairperson .................................                      Secretary .....................................