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CCC Membership Application
Applicant Information
Email address *
First Name *
Last Name *
Spouse (If applicable, otherwise write "N/A") *
Phone Number *
Have you ever been proposed for membership in this club before *
If so, when and with what result?
REFERENCES
Provide references of at least two (2) current members of the club.
Reference # 1 *
Reference # 2 *
Send payment to P.O. Box 118, the clubhouse (883 County Rd. 1350 N, Carmi, IL 62821)
Membership options are on the "Memberships" page on the website.
Enter the date and your initials below as your signature of application.
Date *
MM
/
DD
/
YYYY
Initials *
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