Membership Application Form

Membership Application

To apply for membership, please complete all questions.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
example@example.com
Date of Birth *

Month Day Year
Date
Home Number
Mobile Number *
Work Number
Completed Education Level *

Undergraduate degree Graduate degree Law degree Medical degree Doctoral degree Other
Are you active on social media? Check all that apply and list your account names below. *

Linkedin Facebook Instagram TikTok
Linkedin Account
Facebook Account
Instagram Account
TikTok Account
What is your professional status? *

Corporate employee Entrepreneur Unemployed Other
What is your job title? *
Briefly describe your job responsibilities? *
Are you an entrepreneur? *

Yes No
What is the name of your business?
Briefly describe your business.
List your business' website.
Have you ever been a member of a dinner club? If yes, list the name of the club below. *
Are you a member of other social organizations? List names below. *
Why is Dine Couture of interest to you? *
Identify the membership payment type that you are likely to select. Payment will not be due until the application is approved. *
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1 Year Membership (full payment) includes $1,500 annual fee + $200 one-time administrative fee
$ 1,700.00

1 year Membership (3 installments) includes one payment of $580 + $200 one-time administrative fee (2 remaining payments of $580 each)
$ 780.00
Signature *

Clear
Signature Date *

Month Day Year
Date
Thank you for your interest in Dine Couture, the premiere dining society for modern, professional women seeking to upgrade their social lives through fine dining experiences.

A member of our team will be in touch with you to schedule a virtual meeting to get to know you better.

Your application will be reviewed within 72 hours.
Your information will not be shared and will be kept safe and confidential. By proceeding, you agree to Dine Couture's Terms and Conditions and Privacy Policy.
Please verify that you are human *
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