Membership Application
Applicant Information
Name:
Date of birth:	SSN:	Phone:
Current address:
City:	State:	ZIP Code:
Own Rent (Please circle)	Monthly payment or rent:	How long?
Employment Information
Current employer:
Employer address:	How long?
Phone:	E-mail:	Fax:
City:	State:	ZIP Code:
Position:	Hourly Salary (Please circle)	Annual income:
Emergency Contact
Name of a relative not residing with you:
Address:	Phone:
City:	State:	ZIP Code:
Relationship:
Spouse Information if joint membership
Name:
Date of birth:	SSN:	Phone:
Spouse Employment Information
Current employer:
Employer address:	How long?
Phone:	E-mail:	Fax:
City:	State:	ZIP Code:
Position:	Hourly Salary (Please circle)	Annual income:
References
Name	Address	Phone
Children if membership privileges desired
Name	Name
Name	Name
Signatures
I authorize the verification of the information provided on this form as to my credit and employment. I have received a copy of this application.
Signature of applicant:	Date:
Signature of spouse (only if for a joint membership):	Date: