Black Russian Terrier Club of Northern New Jersey

New Jersey Regional Club


Black Russian Terrier Club of Northern New Jersey

Renewal Membership Form

Member(s) Name: ________________________________________________________




City, ST, ZIP:___________________________________________________________



Renewal Membership Dues:

Black Russian Terrier Club of Northern New Jersey dues are due now for the membership year of  20___ . Any dues received after March 1st, 20___ is a lapse in membership and would need to reapply.

Please get your dues in before March 1st, 20____ to avoid lapse in membership


Dues are as follows:

Individual Membership - $25.00 U.S. Funds per year - open to any owner 18 years or older 

Family Membership - $40.00 U.S. Funds per year family member over 18 years of age with two votes

Associates Membership - $25.00 U. S. Funds per year open to non owners  No voting rights


Please make check payable to Black Russian Terrier Club of New Jersey

Please make any corrections to keep your information updated, sign & return form with payment to Vincent Modica


Your donations are greatly appreciated this help us off set the cost for insurance, ribbons, trophies, fees for running our shows and food.  

Donation: $___________


Membership Fee Enclosed $                  Individual (     )    Family   (    )    Associates   (     )  (please check one)


Total amount enclosed: $_____________     


Family Membership Please list all family members if you have a Family membership. Thank you.


Home Phone #: 

Fax #:                                                                      

Kennel Name:   




Do you still own a registered Black Russian Terrier: YES (   ) NO(   ) How Many?______

If yes, what is the registered name of your dog?: 



Do you approve of your contact information being posted on: Website: Yes (    ) No (    ) Newsletter: Yes (    )  No (     ) 

Any Publication: Yes (    ) No (   ) (please check)


I/We agree to abide by the By-laws as adopted by the Black Russian Terrier Club of Northern NewJersey. and that all the above information is accurate to the best of my knowledge.




Please mail renewal application and dues to:

Vincent Modica

175 Stagecoach Road

Cape May Court House, NJ 08210


Black Russian Terrier Club of Northern New Jersey  -  Thanks you for your support!