Benny's Room Member Application
Full Name:
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Address:
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Mobile:
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E-mail Address:
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Preferred Method of Contact:
Employer:
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Profession and Title:
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Date of Birth:
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Spouse Name (if applicable):
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Times Frequented Benny's Room:
How did you hear about us?
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Favorite Establishments in the Area:
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Drink of Choice:
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