Application for Clubs to Hold a WC/WCX event

"*" indicates required fields

EASTERN REGION
Hank Hahn (ambikagr@optonline.net)
315 Madison Ave
Hasbrouck Heights, NJ 07604-2009

CENTRAL REGION
Peg Burlett (auretrieve@netzero.net)
3655 Brauer Road
Oxford, MI 48371

WESTERN REGION<
Rita Robins (rsrobins@verizon.net)
3920 Merritt Road
Sachse, Texas 75048-4610

Name

First Last

Name of Club

Test Date

Region*

Test Location

Judge

AKC#

Qualification of Judge

Judge 2

AKC#

Qualification of Judge

Judge 3

AKC#

Qualification of Judge

Judge 4

AKC#

Qualification of Judge

Judge 5

AKC#

Qualification of Judge

Game Bird

Pheasants

Pigeons

Guinea Hens

Ducks

Chukhars

Agreement

I agree

Chairman Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GRCA Committee Member 1

GRCA Committee Member 2

GRCA Committee Member 3

GRCA Committee Member 4

GRCA Committee Member 5

Send Test Kit to (name)

Send Kit to (address)

Phone

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WC/WCX: GRCA’S Working Certificate (WC) and Working Certificate Excellent (WCX) Program

Application for Clubs to Hold a WC/WCX Event