Membership Application
Single Membership ($25) Couple Membership ($50)
Name
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Single or Couple Membership?
Please Select
Single
Couple
Home #
Cell #
E mail address
example@example.com
Birthday (month/day)
Spouse/SO Information
Anniversary for couples (month/day)
Spouse/SO First and Last Name
Address if Different
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home # if different
Cell #
E mail address
example@example.com
Birthday (month/day)
Today's Date
/
Month
/
Day
Year
Date
To Pay by Check- Choose from the dropdown
CHECK (Will mail)
CHECK (Will bring to the next social)
Make checks payable to: BassLake Area Shag Society OR BASS. Mail to: Dan Brown, 5048 Edwards Mill Road #E, Raleigh, NC 27612 c
For Credit Card payments, choose one of the below to pay with our secure paypal.
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Single Membership
$
25.00
Couple Membership
$
50.00
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