Applicant name: ________________________________________

Business name:______________________________________

Business address (for correspondence):____________________________________________City:___________________ State: ____ Zip: _________

Email:______________

Phone (_____) ______-___________ fax (_____) ______-__________

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INFORMATION for ADVERTISEMENT LISTING:

Farm name: ___________________________________________________________

Farm address: ________________________________________________________City: ________________ State: ____ Zip __________

Web address: ____________________

Email: __________________________

Phone (___) ___-____ Fax (___) ___-____

Koi varieties produced:_________________________________________________________________________________

Wholesale/ Retail (circle as applicable)

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Years in koi breeding ____

AKBA board/interest (check all that apply):

__ Supporting member

__ Officer

__ Assistance with articles and direction

__ Trading stock with other farm members

__ Promoting show awards for American Koi

__ Purchasing contracts for supplies to AKBA members

__ Storage (if needed) of bulk supplies bought for (AKBA) membership

__ Certification/Testing member livestock for SVC/KHV



What do you think is the major obstacle(s) to comparable pricing and marketing of American raised koi?

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__ I have enclosed a check for $75 payable to American Koi Breeders Association.

email: bob@koibreeders.org