Membership Application

Name

First

Last

First Name which applicant generally uses (leave blank if above name is preferred)

Date of Birth

Address

City

State/Province

Zip/Postal

Country

Home Telephone

Name of Business

Business Address

City

State/Province

Zip/Postal

Country

Business Telephone

Preferred Mailing Address

Home

Business

Cellular Phone

Fax

Email

Class of Membership Proposed

List Applicant’s memberships or former memberships in other Clubs

How long has applicant resided in Ottawa?

Has Applicant previously been proposed for membership or been a Member of this Club? If so, when?

Name of Applicant’s Spouse

Name of Applicant's Spouse

First

Last

Spouse’s Date of Birth

Does Applicant wish to receive information on the Club’s Junior and Intermediate memberships?

Yes

No

Does Applicant wish to nominate spouse to membership?

Yes

No

Class of membership proposed (spousal)

Children

Child’s Name

Child's Name

First

Last

Add Remove

Date of Birth

Name of Proposer Sponsoring Member

First

Last

Name two members of the club, other than those appearing above, the Committee may refer to as character references for the Applicant. Provide names and account numbers.

Account Number of Proposer Sponsoring Member

Name of Seconding Sponsoring Member

First

Last

Account Number of Seconding Sponsoring Member