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Enter your personal information
below: |
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Full Name: |
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Date of Birth:
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Home Address: |
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City/Town:
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Zip Code: |
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Home Phone:
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Personal E-mail: |
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Enter your company information
below: |
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Name of Company:
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Title:
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Business Address:
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City/Town:
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Zip Code: |
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Work Phone:
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Company E-mail: |
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Recommended by 100 Club Member
or Public Safety Officer: |
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Member/Officer Name: |
*
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Address: |
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City/Town:
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*
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Zip Code: |
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Phone:
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Member E-mail:
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Marker Plate
Number of car which Shield will be displayed
(Members are limited to a maximum three shields per membership): |
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| Correspondence from Club office
should be routed through: |
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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. |
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Upon acceptance by the Membership Committee you will be notified to remit $250.00 for your first year's dues. |
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Signature of Applicant: |
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Date: |
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Note to new members:
Your dues bill for the next calendar year starting January 1 will reflect any
pro-rated credit for preceding months. |
