Applicant's Name (Print, First, Middle, Last) _____________________________________________________
Spouse (Print, First, Middle, Last)_______________________________________________________
Children’s Name(s) _____________________, _____________________, _____________________,
Age(s) ____________________________________
Street Address City State Zip _______________________________________________________________________________________
Mailing Address City State Zip _______________________________________________________________________________________
Home Phone ___________; Work Phone ____________; Email _____________
Drivers Lic. # ________________________ State _______; SS # ________/________/________
Business Address State Zip _______________________________________________________________________________________
How did you discover us? _______________________________________________________________________
Please provide a personal reference in case of an emergency. _________________________________________
Emergency Phone # _____________________________________
Checking Debit: ___________________________________________________________
Bank Name: ______________________ Routing # ___________________ Acct. # ____________________________
Name on Card: ___________________ Signature: _______________________ Expiration Date: _____________
The following information is necessary for the purpose of extending credit:
VISA card # _________________________________________ Exp. Date: _______________________________
MASTER card # _____________________________________ Exp. Date: _______________________________
MEMBER SIGNATURE _____________________________ Date: _________
MEMBER SIGNATURE _____________________________ Date: _________
Gig Harbor Sailing Club & School: _______________________________________________
Type of membership ______ Total due $ _______________________________ Course fees $ ______ Total received $ _______________________________ Balance Due $ ______________________________________ Initiation fee $ ______ Payment Option CK. CA. |