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Application for Membership ~ Continued Names of other Club Members with whom I am acquainted

I am/have been a Member of the following clubs

Other Information About Yourself

CONSENT TO COLLECTION AND USE OF INFORMATION I understand that the information provided by me in this Application for Membership is required by the Club in order for its Board of Directors to assess my eligibility for membership in the Club and, if I am admitted as a member, that this information shall be retained by the Club and used by the management and administration of the Club to extend the benefits and obligations of membership to me. I consent to the collection, retention and disclosure of the information contained in this form for those purposes only. This application is for the person noted and does not include the Spouse or Child. I authorize Burlington Golf and Country Club to conduct background enquiries into myself in connection with my application to become a member of the Burlington Golf & Country Club. Therefore, until informed in writing to the contrary, I hereby authorize and direct you to release to the Burlington Golf & Country Club and/or its authorized agent any information concerning my credit history and/or other information relevant to my application. To this end, I attach a void cheque.

Applicant—(Please print name) Signature of Applicant

SPONSORS — (Golf Applicants Only) We the undersigned members of BURLINGTON GOLF & COUNTRY CLUB, LIMITED are personally acquainted with the above applicant. We recommend him / her for admission to the membership.

Proposer—(Please print name)

Account Number

Signature

Seconder—(Please print name)

Account Number

Signature

FOR OFFICE USE ONLY

Date Received

Account #

User/Pass

Locker

Posting Period

Board Approval

Deposit Amount

Director Signature Date Membership Chair Date

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