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Application for Membership
print friendly application
Applicant's Personal Details
  		          Spouse's Personal Details
 
Title:           Title:
First Name:           First Name:
Last Name:           Last Name:
Social Security #:          
Gender: Female Male           Gender: Female Male
Birthday:           Birthday:
Age Group:           Age Group:
 
Contact Information - Home
 
Home Address:    
       
City:    
State:    
Zip:    
Home Phone:    
Home Fax:    
Home Email:    
 
Contact Information - Business
 
Employer:    
Profession:    
Business Address:    
       
City:    
State:    
Zip:    
Business Phone:    
Business Fax:    
Business Email:    

Preferred Mailing Address: 		   
Home Business
 
Application Type
 
Member Category:     Regular Member
        Associate Member
 
Referred by:    
 
Spouse Card:

 		    An additional membership card can be provided
for your spouse for a $5.00 fee.
Yes Please No Thanks
 
Billing
 
Initiation Fee
will be paid by: 		    Visa or Mastercard
Check
 
Monthly Dues
will be paid by: 		    Visa or Mastercard
Payroll deduction (UofL employees only)
Bill me each month
 
I understand that there is a 1.5% finance charge per month on any unpaid balance.Cancellation of membership must be submitted in writing to the membership director along with any balance due.

Please allow five days for processing.