Resident Stock Voting Membership - Petroleum Club of Lafayette

RESIDENT VOTING STOCK MEMBERSHIP APPLICATION

Voting Stock Membership - 12 month commitment

Applicant must reside within a radius of 5O miles of the City of Lafayette. A stock certificate will be issued for each resident Voting Membership.

Stock Certificate is to be issued and mailed to:

Stockowner

Attention

Address

Apt, Suite, etc.

City

State

Zip

Member Date of Birth

Spouse's Name

Spouse's Date of Birth

Wedding Anniversary

*Name entered above will be the owner of the stock. This cannot be changed without Board of Directors approval.

My principal business activity is (please describe)

Have you ever been a member of the Petroleum Club of Lafayette?

Do you derive the majority only income from my efforts in the oil & gas industry?

Name of Applicant

MR.
MRS.
MISS.
DR.

Company

Position

Mailing Address

Apt, Suite, etc.

City

State

Zip

Cell Phone

Work Phone

Email Address

Social Security or Employer ID

Hobbies 1.

Hobbies 2.

Hobbies 3.

All Applications are Submitted on the Fourth Monday of Each Month for Board Consideration.

I understand that I'm personally responsible for all charges I incur at the Club. initials

Member Sponsors (Signatures Required)

Primary Sponsor

Primary Sponsor Number

Signature of Applicant

Secondary Sponsor

Secondary Sponsor Number

Secondary Sponsor

Secondary Sponsor Number

Home Address

Apt, Suite, etc.

City

State

Zip