Empire Lounge Membership Application
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Age:
*
-
Month
-
Day
Year
What interests you most about becoming a member of Empire Lounge? (e.g., Networking Opportunities, Exclusive Events, Premium Amenities)
*
Please list any specific member benefits or amenities you are looking for. (e.g., Priority Reservations, Guest Passes, Discounts on Services)
*
How often do you plan to visit Empire Lounge?
*
Please give reference of whom referred you:
Rows
Full Name
Contact Number
1
2
Membership Options
*
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next
( X )
Yearly Membership
$
1,200.00
Monthly Membership
$
100.00
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: