Membership Application Application InstagramThis field is for validation purposes and should be left unchanged.MEMBER INFORMATIONMember Name(Required)Primary Email(Required) Cell Phone(Required)Office PhoneDate of Birth(Required) MM slash DD slash YYYY COMPANY INFORMATIONCompany NamePosition/TitlePREFERRED MAILING ADDRESSAny mail sent by the Club should go to my:(Required) Home Address Business Address Address Section(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code REFERRED BYMember of the 1818 Club (if applicable)OtherOther Club AffiliationsSPOUSE INFORMATIONSpouse NameSpouse’s Primary Email Date of Birth MM slash DD slash YYYY Wedding Anniversary MM slash DD slash YYYY Spouse’s Email Preferences: Subscribe to Club Newsletters Do not subscribe MEMBERSHIPI am applying as:(Required) Individual - General Membership - $175 Monthly Company - General Membership - $175 Monthly Non-Profit - Special Rate Membership - $112.50 Monthly Elected Official - Special Rate Membership - $112.50 Monthly Young Executive (21 - 35 years old) - Special Rate Membership - $112.50 Monthly Club Package: 3-5 Members - $140 per person monthly Club Package: 6-9 Members - $122.50 per person monthly Club Package: 10+ Members - $105 per person monthly ACCOUNT PREFERENCESBilling statements should go to:(Required) My Primary Email Accounts Payable Both Account’s Payable Email (if applicable) A COMPANY MEMBERSHIP is administered by a corporation or firm. A designee is determined by the company as the person entitled to membership. There shall only be one designee per company account, but he or she can be changed at anytime with an officer’s approval. As a duly authorized officer of the company, the undersigned certifies and agrees that said company unconditionally guarantees all dues and charges due and payable to the 1818 Club incurred by:SignatureDate Signed(Required) MM slash DD slash YYYY
