Full Name*
| Membership Class* (enter membership class applying for)
|
Date of Birth *
| Age *
|
Are you married? *
Yes No | If so, Full Name of Spouse
|
Spouse Date of Birth
| Spouse Age
|
|
Child Name
| Child Date of Birth
|
Child Name
| Child Date of Birth
|
Child Name
| Child Date of Birth
|
Do you desire a Family Associate Membership?
Yes No | Do you desire Junior Membership for your children age 16 or over?
Yes No |
|
Residence Address *
| Years resided in Cleveland *
|
Phone *
| Email *
|
|
Your Occupation
| Business Name
|
Business Address
| Business Phone
|
Business Email
| Business Fax
|
|
Spouse's Occupation
| Spouse Business Name
|
Business Address
| Business Phone
|
Business Email
| Business Fax
|
List organizations of which you are a member (Clubs, Professional Associations, Civic Groups, etc.) Indicate any office held in these groups.
|
List religious affiliations
|
Were you ever refused application to or expelled from any Club or Organization?
Yes No
If Yes, Explain
|
Names of family members (brothers, sisters) who are Beechmont members:
| Please list Beechmont members you know:
|
Philanthropic participation and contributions
Itemize each charity or organization and amounts donated, for the past three years.
(Do not include dues to religious organizations or donations of household goods.)
|
I hereby affirm that to the best of my knowledge, the foregoing information is true and correct. I hereby authorize Beechmont, Inc. to investigate and to verify the contents of this application and such other elements as it may in its discretion deem relevant to act upon this application, including but not limited to a criminal background check. If elected to membership, I agree to comply with the Constitution of Beechmont, Inc., its Bylaws and Regulations and to pay the required initiation fee and all dues and assessments. I understand that anyone acquiring Junior or Associate Membership through me will have only those club privileges conferred upon me. I understand and agree that if I change my membership level or discontinue my membership, I must give 90 days notice. I will pay all charges that I have incurred, as well as any assessments that may be levied for the time I was a member, even if they are levied after my resignation became effective.
A PHOTOGRAPH MUST ACCOMPANY THIS APPLICATION |
Date *
| Applicant's Signature * (type full name)
|
| |
