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Membership Application
2009-05-03
NAME: ______________________________TELEPHONE: __________________
HOME ADDRESS: ______________________HOME FAX: __________________
____________________________________EMAIL ADDRESS: ______________
OCCUPATION: ________________________
BUSINESS ADDRESS: __________________TELEPHONE: _______________
____________________________________FAX: ________________________
____________________________________
DATE OF BIRTH: _____________NAME OF SPOUSE: _________________
YES, I HAVE READ THE PICKWICK PAPERS
I, the undersigned, agree as a condition of membership, to abide by the RULES of THE PHILADELPHIA PICKWICK CLUB, and to pay the joining fee of $125.00 plus the annual membership subscription of $190.00.
PROPOSED BY: _______________________SECONDED BY: ______________
ANNUAL SUBSCRIPTION: $190.00 JOINING FEE: $125.00
FIRST LUNCHEON ATTENDED: ___________
SECOND LUNCH ATTENDED: ___________
APPLICANT SIGNATURE: ___________________________DATE: _____________
*************************************************************
APPROVED: _____________________________DATE: _______________
(Chairman of Membership)
PICKWICKIAN CHARACTER: ____________________________________________
Please return completed form to: Terry Lacey, 1112 Perry Ln, Collegeville PA 19426-1068.