Chesapeake Bay Retriever Relief & Rescue
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Member Application
Verify Your Name
Enter Applicant Email and Name
Please Enter the Applicant's email address and Full Name. The email and name you enter should match what's in their user profile on the organization's web site
Email
First Name
Last Name
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Welcome,
, to the Member Sign-Up Form
Please make changes to your Name and Profile in the
CBRR&R Web Site Profile
Age
We're sorry 18 years-of-age or older to become a Member. However, your Parent or Guardian may become one.
MemberShip Type
Select the type of membership you are interested in
Will you be the primary member for your family?
Enter the email address of the primary member in your family
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Children
Enter Number and Ages of Children
Children?
Number and Ages
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Chessies
Chessies Owned
Have you owned or do you now own a Chessie?
If Yes, how many and for how long?
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Occupation
Enter an Occupation. If none, write 'None', 'Retired', etc.
Occupation
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Address
Enter your address
Street Address 1
City
State
Zip
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Email(s)
Enter your email. A valid mail is required
Email
Secondary Email
Preferred Email for Contact
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Phone(s), Fax
Enter your phone number(s)
Home Phone
Work Phone
Mobile Phone
Fax
Preferred Phone
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Member Info
Enter areas of interest that willing to help with:
Other Services
Coverage Area
Local club affiliations
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Recommendation(s)
How did you hear about CBRR&R
Other:
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References
Enter References:
Vet Name
Vet Phone
Vet Name 2 or Second Reference
Vet Phone 2 or Second Ref. Phone
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Comments
Comments
Please enter any additional information below that you would like to share as part of this application
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Confirmation and Submittal
Review, Confirmation and Submittal
I,
, confirm the information is correct
Submit
Your Volunteer Application is Submitted. A CBR Representative will be contacting you.
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