Membership Application Fill out the form below or if you prefer, Download the Application I (We) accede to the proposal of my (our) name(s) for membership in the Lafayette Country Club, Inc.; and make the following statements in connection therewith. Note outlining the difference between membership classes goes here. Class of Membership * - Membership Type -LCCBG & CC General Info Full name of applicant(s) (If married, please list complete information for both husband and wife; if unmarried, please fill in applicable sections.) Full Name * Spouse Full Name If the above is a married name, please enter Maiden Name Residence (Number and Street Address)* * City, State, Zip * Home Phone * Home FAX Number Cell Phone Number Email Address * Number of years as a resident of Lafayette? * year(s) If applicant has resided in Lafayette less than five (5) years, please enter the following Former residence (City/State) From Date MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Year End Date MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20142015201620172018201920202021 Year Former Business Connection Employment Applicant Employment Applicant Position * Name of Firm * Business Address (Number & Street/PO Box) * City and State * Business Phone * Business Fax Office Email * Spouse Employment Spouse Position * Name of Firm * Business Address (Number & Street/PO Box) * City and State * Business Phone * Business Fax Office Email * Personal Data Applicant Personal Place of birth * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20172018201920202021 Year University Degree and year Marital Status * Single Unmarried Cohabitants Separated Married Once Divorced Married More Than Once Spouse Personal Place of birth * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20172018201920202021 Year University Degree and year Wedding Anniversary Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Year If Applicants' parents are current members of the Lafayette Country Club, please list their names. Applicant's Parents Names Spouse's Parents Names Children Children under 18 (If you have more than 4 children, add the additional children's info in the comments) New fields will open as children's names are entered. Children under 18 Child Child 1 Full Name Child 1 Date of Birth MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Year Child 1 Gender Female Male Add one Children over 18 (List only those who are unmarried, living at home, and attending college fulltime.) If you have more than the form allows for, add their info in comments. Children over 18 Young Adult 18+ Child Full Name 18+ Child Date of Birth MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Year 18+ Child Gender Female Male Add one Misc and Finalize List other country club affiliations (if any), church memberships, affiliations of memberships in other clubs, societies, organizations, or associations. Comments (and/or other children) or any other information you wish to divulge. If accepted into membership, I (we) agree to be governed by the Articles of Incorporation, By-laws, and Rules of the Lafayette Country Club, Inc. as they are now or as hereafter amended. By entering my/our name(s) below, we agree to the following: All statements above are correct and true to the best of my/our knowledge. My/Our names, below, may be accepted as if we manually signed this document. I/We agree to make the payment of the applicable initiation fee, if any, in a timely manner (which will be refunded in the event that the application is not approved). NOTE: Check or Credit Card is accepted. Applicant Signature * Spouse Signature Sponsored by Submit