| Name:________________________________________ | Breed (mark any that apply): | _____________ |
| Belgian | _____________ | |
| Address:______________________________________ | Clydesdale | _____________ |
| Percheron | _____________ | |
| City, State, Zip:________________________________ | Shire | _____________ |
| Suffolk | _____________ | |
| Phone: (______)_______-________________ | Mule | _____________ |
| Other | _____________ | |
| Class of Membership:___________________ | Enthusiast | _____________ |
| Amount Enclosed:______________________ | Mail to: |
| KDHMA, c/o Charlotte Blake | |
| Date:_________________________________ | 5609 SW Shumway |
| El Dorado, Kansas 67042 |