final final membership application

MEMBER NUMBER

OFFICE USE ONLY

PERSONAL INFORMATION

NAME*

First Name

Initial

Last Name

BIRTHDAY:*

ADDRESS*

Address Line 1

Address Line 2

City

State

ZIP Code

MAILING ADDRESS (IF DIFFERENT)

Address Line 1

Address Line 2

City

State

ZIP Code

CONTACT NUMBER:*

CONTACT EMAIL:*

RECOMMENDED BY:

First Name

Last Name

CREDIT CARD INFORMATION

Blanco Membership Annual

(1) Guest per membership

$ 10.00

Quantity:

Reposado Membership Annual

(5) Guest per membership | $10 Credit Per Month (Expires Monthly)

$ 150.00

Quantity:

Anejo Membership Annual

(10) Guest per membership | Liquor Locker | $15 Credit Per Month (Expires Monthly)

$ 500.00

Quantity:

Credit Card Number

APPLICANT SIGNATURE:

"I AGREE TO ABIDE BY THE RULES OF THE CLUB"

DATE: