Experience Lochland Country Club

Dependent Information Please list any unmarried children under 18, and under 23 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 Newsletter: o Home Email o Business Email Statements: o Home Email o Business Email

I prefer to receive my general mail at: o Home o Business

Member Charge Account Information I hereby authorize Lochland Country Club to process the full balance of my account by credit card or ACH, five days after the statements are issued. Credit card payments will be processed on or about the first day of the month (subject to a 3% courtesy fee). Type o Visa o MasterCard o AmEx o Discover Card Number Name on Card Expiration Date Security Code Billing Address Street City State Zip Code Bank Account ACH: Type o Checkings o Savings Routing Number Account Number Name on Account Security Code Billing Address Street City State Zip Code