Dining Club Application Form

    Applicants Name in full:*:

    Home Address:*:

    City*:

    Postal Code*:

    Phone:*:

    Cell*:

    Cottage Phone:*:

    E-mail*:

    Occupation:

    Name of Firm: (If using a company account please fill in the details)*:

    Business Address:*:

    City*:

    Postal Code*:

    Phone:*:

    Fax:

    Business E-mail*:

    Preferred Credit Card: Mastercard, Visa #*:

    Expiry*:

    CVC/CVV*:

    Date of Applicant’s Birth Month:*:

    Date of Applicant’s Birth Day:*:

    Date of Applicant’s Birth Year:*:

    If married, does spouse wish to have signing privileges?*:YesNo

    Full Name of Spouse:*:

    Date of Spouse's Birth Month:*:

    Date of Spouse's Birth Day:*:

    Date of Spouse's Birth Year:*:

    Spouse's E-mail*:

    Names and birth dates of additional immediate family members:

    Full Name of Family Member #1:

    Date of Family Member #1 Month::

    Date of Family Member #1 Birth Day::

    Date of Family Member #1 Birth Year::

    Full Name of Family Member #2:

    Date of Family Member #2 Month::

    Date of Family Member #2 Birth Day::

    Date of Family Member #2 Birth Year::

    Full Name of Family Member #3:

    Date of Family Member #3 Month::

    Date of Family Member #3 Birth Day::

    Date of Family Member #3 Birth Year::

    I agree: