Individual Membership Application

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you under the age of 18? *

Yes

No

Please check the membership category you are applying for: *

US Resident ($10.00)

Non-US Resident ($0.00) (Non-voting membership)

Under 18 Years ($0.00) (Non-voting membership)

Paying dues by: *

Check

PayPal (You will be invoiced - please check )

I am willing to help the MCA in the following way(s):

MCA Region Ambassador/Representative

Mudi Matters e-Newsletter Committee

Judges / Public Education Committee

Mudi National Specialty Committee

US Mudi / MCA Historian Committee

MCA Board Member / Office Holder

Other (Please describe below)

Member Name 1 *

First Name

Last Name

Member 2 Name: *

First Name

Last Name