New______ Renewal______

Name____________________________________________________

Street____________________________________________________

City______________________________ State_____ Zip___________

Phone______________________ Email_________________________

Local Bird Show____________________________________________
(If you want to sponsor Hartz rosettes for this club's show)

Do you want to be included on the Hartz Breeders List?  Yes___  No___
(If yes, your name, city, state, phone and email will be made public,
if no or no answer, you will only be listed on the private club roster)

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