Membership Application Form for PBCC

2024 Plum Brook Country Club Membership Application
Applicant does hereby willingly provide the following information to Plum Brook Country Club for consideration in obtaining membership acceptance. Applicant further agrees that Plum Brook may use any or all of the provided information in making its determination.
General Information
APPLICANT Name*

First NameLast Name
SPOUSE / SIGNIFICANT OTHER

First NameLast Name
APPLICANT PREFERRED Name

First NameLast Name
SPOUSE PREFERRED Name

First NameLast Name
PERSONAL Email*
SPOUSE / SIG OTHER Email
PERMANENT Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OTHER Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PERSONAL CELL Phone Number*
Format: (000) 000-0000.
OTHER (HOME) Phone Number
Format: (000) 000-0000.
SPOUSE PERSONAL CELL NUM
Format: (000) 000-0000.
DATE OF BIRTH APPLICANT*

MonthDayYear
Date
DATE OF BIRTH SPOUSE

MonthDayYear
Date
APPLICANT EMPLOYER*
EMPLOYER ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMPLOYER PHONE

Area CodePhone Number
EMPLOYER EMAIL
example@example.com
POSITION / TITLE
CHILDREN / AGE (under age 25 living with applicant)
MEMBERSHIP TYPE

(PLEASE PICK ONE FROM DROPDOWN BELOW PRICING)

PLEASE PICK A MEMBERSHIP TYPE*
- Members paying a discounted rate will increase annually until they reach Full Dues level. Increase is determined each year by the Board of Directors, currently $500.00/Golf and $250.00/Social.
- The Board of Directors reviews all Dues each year to assure the continued financial stability of the club.
- An annual Assessment, while rare, may be imposed by the Board of Directors.
- New Member discounted Dues must be paid in full prior to Membership acceptance. New Member will remain on an annual dues invoice basis until they reach three years of membership or Full Dues status. Afterward they may choose monthly dues invoicing.
- Initiation fees must be paid in full prior to membership consideration.
- Monthly required food and beverage (including alcohol) is $65.00 for twelve months. Non-Resident Category is for four months.
- There are NO refunds of Dues or Fees
Junior Dues Schedule (Age - Amount)

*All Junior Golf and Junior Social fees listed below do not include the one-time, first year initiation fee of $1,000 (golf ages 21-29), $2,000 (golf ages 30-36), $2,000 (social ages 21-36).

Emergency Contacts
Emergency Contact #1*

Contact 1 First NameContact 1 Last Name
Emergency contact #1 Phone*

Area CodePhone Number
Emergency Contact #2

Contact 2 First NameContact 2 Last Name
Emergency contact #2 Phone

Area CodePhone Number
Individuals Authorized To Charge To Applicant's Account
Signer #1

Contact 1 First NameContact 1 Last Name
Signer #2

Contact 1 First NameContact 1 Last Name
Signer #3

Contact 1 First NameContact 1 Last Name
Signer #4

Contact 1 First NameContact 1 Last Name
Acknowledgement
Applicant hereby acknowledges agreement with all Rules, Regulations and By-Laws of Plum Brook Country Club (“Club”) and warrants use of the Club and privileges under the membership category desired are subject to the terms, conditions and restrictions set forth therein. The Club, in its sole discretion, reserves the right to change or amend the Membership Categories, Dues, Assessments, Rules, Regulations, By-Laws and Code of Regulations, to terminate memberships and to discontinue operations of any or all of the Club facilities, either temporarily or permanently. Applicant warrants that the desired membership is for the sole purpose of obtaining recreational use of the Club facilities and not as an investment or for economic gain or profit.
APPLICANT Signature

Clear
DATE SIGNED

MonthDayYear
Date
PLUM BROOK COUNTRY CLUB

Received by: _________________________________

Date:_____________________

Accepted this ________ day of __________________, 20___
Should be Empty:

2024 Plum Brook Country Club Membership Application