Name______________________________________________________ Date of Birth_______________SS#________________________

Spouse’s Name _______________________________________Date of Birth__________________________

Significant Other ______________________________________Date of Birth__________________________

Home Address_______________________________________________City___________________________State_________Zip________

How long at this address? _______________ Prior Address if less that 5 years_________________________________________________

Home Phone #____________________Cell Phone #___________________________E-Mail_____________________________________

Billing Address, if different_________________________________________________________________________________________

Dependent Children under 25 – Name/Date of Birth_____________________________________________________________________

_______________________________________________________________________________________________________________

Employer__________________________________Job Description______________________Length of Employment here____________

Business Address__________________________________________________________Work #_________________________________

Previous Employer, if less than 5 years here______________________________________________________Phone #_______________

Affiliations with Other Clubs/Organizations___________________________________________________________________________

INDIVIDUAL_______________________FAMILY________________CORPORATE________________

FAMILY______ ACTIVE ADULT______ AA W/SOCIAL FAMILY__________EXECUTIVE FAMILY______

JUNIOR FAMILY____________JUNIOR SINGLE____________SOCIAL___________NON-RESIDENT__________

My initiation fee of ____________, along with my stock purchase fee ________accompanies this application with the understanding

that, if the Board does not approve this application all monies will be refunded to me. I understand that during the application process

I will be required to have an interview and orientation with the Membership Committee, who makes all recommendations to the Board

for final approval. If membership is approved, I agree to a 14 month commitment to membership beginning when the application is signed,

I understand there will be an increase in dues beginning April 2010, and acknowledge that all persons using the Club

under my membership, including guests, are bound by and shall comply with all the by-laws, rules and regulations of the Club.

Applicant (s) Signature________________________________ ________________________________________________

Date: __________________

Accepted this _________day of_____________________20_______ By:_______________________________________________

Director of Marketing and Membership