First Name_____________________________

 Middle Name___________________________

 Last Name_____________________________

 Social Sec. #___________________________

 Date of Birth___________________________

 Spouse First Name______________________

 Spouse Middle Name_____________________

 Spouse Last Name_______________________

 Spouse Social Sec. #_____________________

 Spouse Date of Birth______________________

 Company/Partnership Name _______________

______________________________________

 Federal Tax ID# ________________________

 Address 1 _____________________________

 Address 2_____________________________

 City__________________________________

 State_________________________________

 Zip__________________________________

Home Phone #_________________________

Business Phone #_______________________

Mobile Phone #_________________________

FAX #________________________________

EMAIL _______________________________

TYPE OF MEMBERSHIP

                REGULAR $55
                              * Must own or be part owner
                                 of at  least one Thoroughbred
                                 horse maintained for racing or
                                 breeding in Colorado.

                 LIFETIME $600
                               * Same as Above

                  
                  ASSOCIATE $40
                                * Cannot own or be part owner
                                    of any Thoroughbred horse
                                    maintained for racing or
                                    breeding in Colorado.  Will
                                    have NO voting rights.


 # of Mares ____________________________

 # of Stallions __________________________

 # of Foals _____________________________

Thank-you again for taking the time to fill out the new form.  C.T.B.A. Office
Membership Application

Colorado Thoroughbred Breeders Association

22 South 4th Avenue, Suite 102

Brighton, CO  80601


Phone:  303-294-0260

Fax:  720-230-4563

Email:  ctba@cotba.com

Colorado Thoroughbred Breeders Association