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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