PURPOSE OF FORM *

If modifying personal information please only fill out for the section requiring modification. If a name change is required please indicate both old name and new name.

Applying for New Membership

Modifying Personal Information

Terminating Membership

Name *

First Name

Last Name

Phone

(###)

###

####

BIRTHDATE *

MM

DD

YYYY

*

I, , agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent that the information provided is truthful and correct.