Widows' and Widowers' Privileges

I wish to apply for signing privileges as a widow of a member. I authorize you to charge annual dues and all usage fees for these privileges to my Club account. I assume full responsibility for the payment of these charges. The annual fee for this privilege is 50% of the annual dues for the regular membership category.
Your Information
Your First Name (required):*
Your Last Name (required):*
Your Email (required):*
Date of Birth (required):*
Date Format: MM slash DD slash YYYY

Format: mm/dd/yyyy
Your Phone (required):*
Your Gender*
- Male
- Female
- Other
Your address if different from Member resident address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Deceased Member's Information
Deceased Member's Audit Number (required):*
Deceased Member's Name (required):*
Date of Death (required):*
Date Format: MM slash DD slash YYYY

Format: mm/dd/yyyy
Consent*
- By checking this box, I hereby sign and authorize the Welcoming Committee to make any necessary actions and inquiries to process this application. I also agree to abide by the Club's By-Laws and House Rules if I become a member and to pay when due all Club charges when invoiced to me.
Please Verify:

Your Information