Membership Application

type of membership desired  (check ONE MEMBERSHIP)
 Golf 40+
Food Minimum $100/quarter
 Golf 35-39
Food Minimum $200/quarter
 Golf 21-34
Food Minimum $200/quarter


 Athletic 40+
Food Minimum $200/quarter
 Athletic 35-39
Food Minimum $200/quarter
 Athletic 21-34
Food Minimum $200/quarter
 Dining 

PERSONAL INFORMATION
First Name*
M.I.
Last Name*
Date of Birth 
Marital Status 
Single  Married
Current Address
City
State
Zip Code
Length of Time at Current Address


  


Email Address 
Home Phone Number
Cell Phone Number 
 
Applicant's Occupation or Business
Position
Employed By
 
Have you ever been convicted of a felony?
 Yes  No
If so, explain

Spouse (or Spouse Equivalent)
First Name
M.I.
Spouse Last Name
Date of Birth 

Email Address 
Spouse Phone Number
Business Phone Number 
 
Spouse's Occupation or Business
Position
Employed By

Dependent Members (Please list your unmarried children under the age of twenty-six.)
Legal First Name
M.I.
Legal Last Name
Date of Birth 
Gender
M  F
Legal First Name
M.I.
Legal Last Name
Date of Birth 
Gender
M  F
Legal First Name
M.I.
Legal Last Name
Date of Birth 
Gender
M  F

Reference information
Please list membership in other Clubs, fraternities or organizations and positions held:
Club Name
Location
Phone Number
Club Name
Location
Phone Number
Have you ever been proposed for membership in this or any other Club
and been rejected or had your application withdrawn?

 Yes  No
If so, please explain
I am acquainted with the following Fort Wayne Country Club Members:
First Name (Proposer) 
Last Name (Proposer) 
Years Known
First Name
Last Name 
Years Known
First Name
Last Name 
Years Known
First Name
 Last Name
Year Known

background & credit information
Please list existing Bank Reference:
Name of Institution 
Branch 

Contact Name 
Phone Number 
Fax Number
Please list two credit references:
First Name 
Last Name 
Phone Number
First Name 
Last Name 
Phone Number

authorization
By signing this application for Membership Invitation at Fort Wayne Country Club, I hereby authorize Fort Wayne Country Club, through its representatives, to make inquiry of my financial condition, our family and professional background and specifically authorize them to make inquiry of consumer credit reporting organizations, Divisions of Motor Vehicles, and those charged with maintaining criminal records. The undersigned does hereby acknowledge, accept and understand that I have truthfully and to the best of my ability answered all application questions.
Signature of Applicant*  (type name)    Date*
Signature of Spouse (type name)    Date