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Board Member taking Application ____________
Date ___________________
Receipt number _____________________
Key charge ________ Key yes no n
NAME: ___________________________________________________________________________________
ADDRESS: ________________________________________________________________________________
CITY: ___________________________________________STATE: _________________ZIP: _____________
PHONE NUMBER EMAIL ADDRESS
SOBRIETY DATE: __________________________________________________________________________________________
OCCUPATION: __________________________________________________________________________________________
PRIMARY REASON FOR JOINING THE 521 CLUB __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
HOW DID YOU HEAR ABOUT US? __________________________________________________________________________________________
__________________________________________________________________________________________
RECEIVED COPY OF BY-LAWS _________________________________(INITIAL)
NOTE: AFTER JOINING THE CLUB, IF YOU SHOULD HAVE ANY PROBLEMS PAYING YOUR DUES COME SEE A BOARD MEMBER INSTEAD OF STAYING AWAY. |
