Membership Application APPLICANT INFORMATION Membership Application Applicant information Name(Required) Date of Birth MM slash DD slash YYYY MobilePhoneHiddenAddress Street Address City State:AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Address City State Zip Code Email(Required) SPOUSE INFORMATIONName Date of Birth MM slash DD slash YYYY MobileREFERRING MEMBERName Address Phone Name Address Phone CIGAR & LIBATION PREFERENCESPreference Preference Preference Preference Preference Preference MEMBERSHIP TYPESpouse Membership Type Corporate - $1250 annually Spouse Membership Type Associate - $300 annually (no locker storage) Spouse Membership Type Gold - $500 annually Spouse Membership Type Associate - $30 monthly (no locker storage) Spouse Membership Type Gold - $50 monthly SIGNATURESConsent(Required) I authorize the verification of the information provided on this form. I have received a copy of this application.(Required) Δ
