2024 Membership

Application

Member Information

Please complete all information

Member Name

Date of Birth: *

Residence Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

E-mail Address:

Employer:

Business Address:

Business City:

Business State:

Business Zip:

Business Phone:

Family Information

Spouses Name:

Date of Birth: *

Children’s Names:

Date of Birth: *

Children’s Names:

Date of Birth: *

Children’s Names:

Date of Birth: *

Wedding Date (M/D):

Previous Club History

Are you now or have you ever been a member of VCC or another club?

Yes

If so, Name of Club:

City:

State:

Dates of Membership:

Offices Held?

I understand this application is subject to approval of the Board of Directors of the Valparaiso Country Club and upon approval for membership, the initiation fee is non-transferable or refundable. If accepted for membership, I agree to abide by the constitution, by-laws, rules and regulations of the Valparaiso Country Club. I will submit payment of all dues, assessments, charges and taxes on a monthly basis. I agree to pay a 1.5% per month late charge fee for any late payment (1 day past due date) plus any collection fees or court costs for any past due account balance.

Please attach a voided check if you wish for us to charge you checking account monthly for you monthly bill.

Choose

Signature:

Date of Application:

Board Approval:

Date of Approval:

Submit