Elk Membership Application

New Port Richey Elks Membership Application

We're so excited to have you join us! You're going to have a blast with us.

How did you hear about us?*

Friend or FamilyOne of our eventsAn adGoogle searchOther

Are you above the age of 21 years old?*

YesNo

Do you believe in God and are you willing to attest to that belief?*

YesNo

Are you a citizen of the United States of America who will pledge the allegiance to and salute our Flag?*

YesNo

Name*

First NameLast Name
Maiden Name if Applicable

Maiden Last Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Street Address*
City*
State*
Zip Code*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Confirm Email Address*
example@example.com
Sorry, the emails do not match.
By checking this box, I hereby authorize the Lodge newsletters and statutorily required notices pursuant to Section 1.115 of the Grand Lodge Statutes by email or other electronic means at the personal email address listed above. This includes receiving emails from the Benevolent and Protective Order Of Elks New Port Richey Lodge 2284*

YesNo

Your Occupation:*
Business Name:
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Telephone
Please enter a valid phone number.
Business Email
example@example.com

Are you foreign born?*

Not foreign bornForeign born

If foreign born, when and where were your final naturalization papers issued?*

MonthDayYear
Date
Please upload your naturalization papers as they are required.*

Cancelof

Are you willing to assume an obligation that: (a) Will not conflict with your duties to yourself, or your family, or your religious or political opinions, and that (b) Will bind you to uphold the Constitution and laws of the United States of America?*

YesNo

Are you now a member of or directly or indirectly participating in the activities of any group or supporting or adhering to beliefs or tenets advocating the overthrow of the Government of the United States or any of its political subdivisions by for or violence?*

YesNo

Have you ever pleaded guilty or no contest to or been convicted or a felony or crime or moral turpitude? (Any such plea or conviction must be disclosed even if the case was later expunged or dismissed. Such disclosure will not automatically prevent your membership in our Order, but may be a factor to be considered by the membership). I understand that the Lodge may perform a criminal background check to verify the information provided.*

YesNo

Have you ever served in the armed forces of the United States of America?*

YesNo
If yes, state the type of discharge and branch of service

Have you ever been proposed for membership in any Elks Lodge?*

YesNo
If yes, please provide the Lodge name, date, and result:

Have you been a bona fide resident within the jurisdiction of this Lodge immediately preceding the date of this application?*

YesNo

Proposer Information
Do you have an Elk member proposing you for membership?*

YesNo
Name of Proposer (If none, leave blank)

First NameLast Name
Email of Proposer (If none, leave blank)
example@example.com
Telephone Number of Proposer (If none, leave blank)
Please enter a valid phone number.
Membership Number of Proposer (If none, leave blank)
Lodge Name & Lodge # (if none, leave blank)

Application Method
The Lodge Dues per annum are paid annually in advance of April 1st of each year or annually in advance on April 1st of each year, as provided in the By-Laws of the Lodge. An applicant rejected must wait six months before reapplying for membership. Rejected Applicants shall have their Initiation Fees returned to them by the Lodge.

Should a candidate fail, without good cause, to appear for Initiation within four months from the date of the Candidate's election, the Exalted Ruler shall declare the Candidate's right to Initiation (under such application and ballot) void and the Candidate's Initiation fee will be forfeited.

I understand that this application must be fully completed and accompanied by any application and initiation fees required by the Lodge; and that pro-rata membership dues, assessments and state association dues and fees, for the current year, must be paid at the time of initiation. I further understand that the Benevolent and Protective Order of Elks is a private organization, and that if I do not meet the established requirements and receive membership approval, I will not be granted admission into the Order.

I agree that my electronic signature below will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. If you do not agree, you have the option of completing a paper application at our Lodge. Please see our Terms of Service here.
Signature*

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Elk Membership Application Fee*

Elk Membership Application Fee Product Image

Elk Membership Application Fee

$25.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Awesome job!

All you have to do now is click the green 'SUBMIT' button in the bottom right-hand corner to send us your application.
Application Method
Application Date

MonthDayYear
Date
Should be Empty: