CCC Membership Application

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Applicant Information

Email address *

First Name *

Your answer

Last Name *

Your answer

Spouse (If applicable, otherwise write "N/A") *

Your answer

Phone Number *

Your answer

Have you ever been proposed for membership in this club before *

Yes

If so, when and with what result?

Your answer

REFERENCES

Provide references of at least two (2) current members of the club.

Reference # 1 *

Your answer

Reference # 2 *

Your answer

Send payment to P.O. Box 118, the clubhouse (883 County Rd. 1350 N, Carmi, IL 62821), or pay online.

Membership options are on the "Memberships" page on the website.

Enter the date and your initials below as your signature of application.

Date *

YYYY

Initials *

Your answer

Send me a copy of my responses.

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