Seniority Lapel Pin Order Form

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/CZ $160.00

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

Hank Williams, Coordinator
ADSJ Seniority Pin Program
8701 NE 37th Avenue
Vancouver, WA 98665


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