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:*:
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:I certify that the particulars listed herein are true and correct. In consideration of being accepted as a candidate for a Dining Club Membership from Port Cunnington Lodge and entitlement to the privileges outlined in this brochure. I hereby agree that I will abide by the Lodge Guest Rules and Regulations (as amended from time to time) and I will pay when due, all debts to PCL Lodge incurred by myself, my family and my guests and that I will be responsible for their conduct on within the Lodge and on the Lodge premises.
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