Member: ___________________________________________________________

Address: ___________________________________________________________

__________________________________________________________________

Original date of approval as an AKC judge: Month ______________ Year ________

Check appropriate space below:

___ 15-20 yrs. sterling silver $30.00
___ 20-25 yrs. sterling w/CZ $40.00
___ 25-30 yrs. gold plated $50.00
___ 30+ yrs. gold plated w/CZ $60.00
___ 25-30 yrs. 10K gold $100.00
___ 30+ yrs. 10K gold w/CZ $110.00
___ 25-30 yrs. 14K gold $150.00
___ 30+ yrs. 14K gold w/C $160.00

Make check or money order payable to ADSJ
Mail this completed form with your payment to:

John Connolly, Coordinator
ADSJ Seniority Pin Program
1925 East Rockwood Blvd.
Spokane, WA 99203