Name:_________________________________________________________________________

Address: _______________________________________________________________________

City:_________________________________________State:______  Zip: __________________

Home Phone: _____ - ______ - ______

Employed by:____________________________________________________________________

Work Address: __________________________________________________________________

City: ________________________________________ State:______ Zip:____________________

Current Rank/Position: ____________________________________________________________

Number of Years as K-9 Handler: _______    Number of K-9's Handled: _______

Name of K-9: ___________________________________   Gender: ___M   ___F       Age: _____

Are you this K-9's first handler?   ___Yes     ___No

                                  K-9's Current Titles and/or Certifications: (Use separate sheet if necessary)
               _____________________________________________________________________________

               _____________________________________________________________________________

K-9's Work Specialties:  (Check all that apply)  ___Explosives    ___Narcotics   ___Patrol
___Tactical Tracking   ___Evidence Recovery   ___Search & Rescue    ___Building Searches
___Human Remains Recovery   ___Corrections-Aggression   ___Contraband Searches

    I, the undersigned, hereby join agreeing that The Association, trainers, officers and members shall
not be held responsible for any personal injury or injury to my animal of damage to personal or department
property during exercises and/or demonstrations held by The Association and agree to abide by all Association
rules and regulations.

Membership Dues: $35.00 / Year

Make Checks Payable to: Southern Tier Police Canine Association

Signed:____________________________________________   Dated: ______________

Please print name of applicant:_________________________________________________________________

  

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