| Northwest Netherland Dwarf Rabbit Club |
| Membership Application 2012 |
| Date:________________________________ Amount Enclosed:__________ |
| Name:___________________________ Birthdate:_________________ |
| Spouse’s Name:___________________ Birthdate:_______________ |
| Name(s) of Children:__________________ |
| Birthdate:_________________ |
| Birthdate:_________________ |
| Birthdate:_________________ |
| Birthdate:_________________ |
| Rabbitry Name:________________________________________________ |
| Address:______________________________________________________ |
| City:_______________________________ State:_____ Zip:____________ |
| Phone Number:_____________________ Email:____________________ |
| Web page address (URL)_________________________________________ |
| ARBA#:___________________________ ANDRC #:________________ |
| Varieties Raised:_______________________________________________ |
| Membership fees: $12 family/partnership, $8 individual, $5 youth (19 & under) |
| Print and mail to NWNDRC Secretary: |
| Anne Ott 1675 Marble Valley Basin Rd. Addy, WA 99101 |