2025 Membership Application Form for PBCC No Pricing

2025 Plum Brook Country Club Membership Application

Revised 3/4/2025
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*
OTHER (HOME) Phone Number
SPOUSE PERSONAL CELL NUM
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
EMPLOYER EMAIL
example@example.com
POSITION / TITLE
CHILDREN / AGE (under age 25 living with applicant)
MEMBERSHIP TYPE
PLEASE PICK A MEMBERSHIP TYPE*
- Members paying a discounted rate will increase annually until they reach Full Dues level listed above. Increase is determined each year by the Board of Directors, currently $500.00/Golf and $250.00/Social.
- An annual Assessment, while rare, may be imposed by the Board of Directors.
- Monthly required food and beverage minimum is $65.00. Non-Resident Category is for four months.
- There are NO refunds of Dues or Fees
Current Memberships Of Other Clubs/Organizations
Please List
Organization name / city & state / Office held if any
Please List
Organization name / city & state / Office held if any
Past Memberships Of Other Clubs/Organizations
Please List
Organization name / city & state / Office held if any
Please List
Organization name / city & state / Office held if any
Emergency Contacts
Emergency Contact #1*

Contact 1 First NameContact 1 Last Name
Emergency contact #1 Phone*
Emergency Contact #2

Contact 2 First NameContact 2 Last Name
Emergency contact #2 Phone
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.
PLEASE ACKNOWLEDGE YOU HAVE RECEIVED Membership PRICING*

I have received and agree with the current pricing and payment plan structure from Plum Brook staff or Directors.
APPLICANT Signature

Clear
DATE SIGNED

MonthDayYear
Date
PLUM BROOK COUNTRY CLUB

Received by: _________________________________

Date:_____________________

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

2025 Plum Brook Country Club Membership Application

General Information

MEMBERSHIP TYPE

Current Memberships Of Other Clubs/Organizations

Past Memberships Of Other Clubs/Organizations

Emergency Contacts

Individuals Authorized To Charge To Applicant's Account

Acknowledgement