Experience Licking Springs Country Club

Dependent Information Please list any unmarried children under 18, and under 25 if dependent is a full-time student.

Name

Age

Birthday

Gender o Male o Female

Name

Age

Birthday

Gender o Male o Female

Name

Age

Birthday

Gender o Male o Female

Name

Age

Birthday

Gender o Male o Female

Statement & Newsletter Preference Do you play golf? o Yes o No How long have you played golf?

USGA Handicap

Does your spouse play golf? o Yes o No

How long?

USGA Handicap

Statement & Newsletter Preference Club Bulletins: o Home Email o Business Email

Monthly Statements: o Home Email o Business Email

Credit Card Information Type

Card Number

Expiration Date

Security Code

Name on Card

Telephone Number

Billing Address

Street

City

State

Zip Code

o Check here to auto-pay statements with credit card 3% fee. Authorization and Agreement

The undersigned hereby confirms that the information provided in this application is true, complete and correct, and authorizes Licking Springs Country Club (the “Club”), through its representatives, to conduct any inquiry into the undersigned’s financial condition and professional background as it considers necessary and appropriate.