Membership Application

Membership categories (check ONE MEMBERSHIP) 
*Membership is a calendar-year commitment. 
 Golf 40+
Food Minimum $50/month
 Golf 35-39
Food Minimum 
$50/month
 Golf 21-34
Food Minimum 
$50/month


 Athletic 40+
Food Minimum 
$50/month
 Athletic 35-39
Food Minimum 
$50/month
 Athletic 21-34
Food Minimum 
$50/month
 Dining 
Food Minimum 
$50/month

personal INFORMATION
First Name*
Last Name*
Date of Birth*  
Marital Status  
Single  Married 
Current Address*
City
State
Zip Code
Length of Time at Current Address


  


Email Address 
Home Phone Number
Cell Phone Number 
 
Applicant's Occupation or Business
Position
Employed By
 
Have you ever been convicted of a felony?
 Yes  No
If so, explain

Spouse (or Spouse Equivalent)
First Name
Spouse Last Name 
Date of Birth  


Email Address 
Spouse Phone Number
Business Phone Number 
 
Spouse's Occupation or Business
Position
Employed By

Dependent Members (Please list your unmarried children under the age of twenty-six.)
Legal First Name
M.I.
Legal Last Name
Date of Birth 
Gender
M  F
Legal First Name
M.I.
Legal Last Name
Date of Birth 
Gender
M  F
Legal First Name
M.I.
Legal Last Name
Date of Birth 
Gender
M  F

Reference information
Please list membership in other Clubs, fraternities or organizations and positions held:
Club Name
Location
Phone Number
Club Name
Location
Phone Number
Have you ever been proposed for membership in this or any other Club and been rejected or had your application withdrawn?

 Yes  No
If so, please explain
I am acquainted with the following Fort Wayne Country Club Members:
First Name (Proposer) 
Last Name (Proposer) 
Years Known
First Name
Last Name 
Years Known
First Name
Last Name 
Years Known
First Name
 Last Name
Year Known
authorization
The undersigned does hereby acknowledge, accept and understand that I have truthfully and to the best of my ability answered all application questions. 
Signature of Applicant*  (type name)    Date*
Signature of Spouse (type name)    Date