Autumn Valley Golden Retriever Club

2012 Membership Dues Renewal

Type of membership:  _____Individual   _____Family

Name(s):______________________________________________________

Address: ______________________________________________________

               ______________________________________________________

Phone#    ______________________home

                ______________________ cell 

E-Mail:__________________________________________

Kennel Name:_____________________________________

Please complete above information, even if no changes, and return with your check or money order payable to AVGRC.

	Return to:     Kelly Wakeman, Treasurer AVGRC P.O. Box 779 Vestal , NY 13850		Amount Enclosed:   Individual $25  _____   Family       $30 _____