Membership Application 

Application Process


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.