Membership Application

Membership Application
Membership Type

Select GoldSelect SilverSelect BronzeDining OnlyNon-Profit/Clergy/Educator/Public Service
Membership Type

SingleCoupleFamily
Primary Applicant
Preferred Phone Number:

HomeCell
Preferred Mailing Address:

Permanent ResidenceBusinessOther
Secondary Applicant

The “Secondary Applicant” may be the Club Member’s spouse or any person eighteen (18) years of age or older who maintains the same principal residence as the Club Member.
Dependents

All unmarried dependents of the Primary Applicant and Secondary Applicant who are each twenty-five (25) years of age or younger and either: (i) maintain the same principal residence as the Club Member; or (ii) are serving in the armed forces or attending school on a full-time basis are hereby designated by the Club Member Applicant to have access to the Club pursuant to Club Member’s Club Membership (proof may be requested):
Name
Date of Birth
Email Address
example@example.com
Gender
School Attending/Military Branch
Nominations (Optional)

Every year, we allow our Club members to nominate up to two individuals, couples, or families for potential Club membership. If you would like to make one or more nominations, please complete the information below.
Briefly desrcribe your relationship with the individual(s) below and why they will be a good fit for Club membership.
Name
Occupation/Title
Name of Business
Permanent Residence Address
City
State
Zip Code
Cell Phone
Email Address

APPROVAL FOR CLUB MEMBERSHIP

I understand that I will not be entitled to Club Membership privileges nor be considered a Club Member until this Application is approved by Club management. The Powhatan Club will determine, in its sole discretion, whether an Application has been approved.

VERIFICATION OF APPLICATION

Upon execution of this Application, I authorize the disclosure and release of information to The Powhatan Club for investigating my qualifications for Club Membership and authorize those persons or entities herein to furnish information to The Powhatan Club.

TERMS OF CLUB MEMBERSHIP

I hereby apply for a Club Membership at The Powhatan Club and acknowledge and agree to the terms of the Membership Agreement:
I understand and agree that acceptance and continuation of Club Membership is subject to payment of all applicable initiation fees, dues, and other charges as may be incurred from time to time. Signature confirms that all information given in this application is correct.
I would like to pay my initiation fee in __ instalments:

1234
Signature of Primary Applicant

Clear
Date
Should be Empty:

Primary Applicant