Home   Application For Membership

Application For Membership

Telephone:  (860) 633-8357
Fax:  (860) 633-8350
E-Mail:  ct100@hundredclubofct.org
Tax Exempt #:  6-6091078

If you wish to print and fax a copy of this application, please click here.

Enter your personal information below.
Full Name (required)

Date of Birth (required)

Home Address (required)

City/Town (required)

Zip Code (required)

Home Phone (required)

Personal E-mail (required)

Enter your company below.
Name of Company

Title

Business Address

City/Town

Zip Code

Work Phone

Company E-mail

Recommended by 100 Club Member or Public Safety Officer.
Member/Officer Name

Address

City/Town

Zip Code

Phone

Member E-mail

Marker Plate Number of car which Shield will be displayed.
(Members are limited to a maximum three shields per membership.)

Plate #1
Plate #2
Plate #3

Correspondence from Club office should be routed through:
HomeOffice

IN ACCEPTING MEMBERSHIP IN THE HUNDRED CLUB IT IS WITH THE UNDERSTANDING THAT ON TERMINATION OF SAID MEMBERSHIP THE CAR SHIELD WILL BE RETURNED TO THE HUNDRED CLUB.

Upon acceptance by the Membership Committee you will be notified to remit $250.00 for your first year's dues.

Signature of Applicant (required) (type your name)

Date (required)

Note to new members:
Your dues bill for the next calendar year starting January 1 will reflect any pro-rated credit for preceding months.

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