Club Membership Registration Form

Club 54235 Membership Form

Complete the form below to sign up for our membership service.
Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Membership Type

$40 annual membership - with your choice of a club t-shirt or 3/4 sleeve t-shirt$60 annual membership - upgrade your membership to receive a club sweatshirt
Choose One Complimentary Gift

t-shirt3/4 t-shirtsweatshirt
Date of Sign Up

MonthDayYear
Date
Agreement to receive texts and emails

I agree to receiving text and email messages as notifications of club events or exclusive benefits for club membership.
Your club membership includes:

·        A t-shirt or sweatshirt

·        Access to exclusive drink discounts

·        Invitations to special club events throughout the year

*Payment accepted at Wickman's 2 Brews (cash or credit).

Thank you for being part of Club 54235. We look forward to serving you another year of great coffee, beer, and fun!
Should be Empty:

Club 54235 Membership Form