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First Name *

Last Name *

Date *

Street Address *

Apartment/Unit #

City *

State *

ZIP Code *

Phone *

Email *

Referred By

Do you have internet access? *

• Yes
• No

Additional family members (spouses, children and students are included under one membership)

Additional family member phone/email

Judge Number (if applicable)

Submit

The Neuse Retriever Club has a 60-member capacity. If the club is currently at capacity, applications received are
put on a waitlist in the event a spot becomes available. Once your application is approved, you will be notified and
must then submit your $100 yearly membership dues.