Full name of applicant(s)
(If married, please list complete information
for both husband and wife;
if unmarried, please fill in applicable sections.)

If applicant has resided in Lafayette less that five (5) years,
please enter the folloiwng

Employment

Applicant

Spouse

Personal Data

Applicant

Spouse

If applicants' parents are current members
of the Lafayette Country Club,
please list their names

Children under the age of 18
(If you have more than the list allows for, add their information in comments)

Children over the age of 18
(List only those who are unmarried, living at home,
and attending college fulltime.)
(If you have more than the list allows for, add their information in comments)

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 Carde is accepted.