2011 Pirate Club Application
❏ Renewal ❏ New Member ❏ Past Young Graduate ❏ 1st Year ❏ 2nd Year ❏ 3rd Year NAME: ❏ Mr.
❏ Mrs. ❏ Ms.
❏ Business ______________________________________
ADDRESS: _____________________________________________________________________
Street
City
State
Zip
CONTACT NAME (If a Business): ___________________________________________________ TITLE: ________________________________________________________________________ HOME PHONE: ( FAX: (
) ________________ BUSINESS PHONE: (
)
CELL PHONE: (
) ___________________
) __________________________
REFERRED BY: _________________________________________________________________
PLEASE COMPLETE PERSONAL INFORMATION EMAIL: _______________________________________________________________________ BIRTH DATE: _____________________________ ECU ALUMNUS YEAR: ________________ LETTERWINNER (Sports): _____________________________________ YEAR(S): ________ SPOUSE’S NAME: ______________________________________________________________ BIRTH DATE: _____________________________ ECU ALUMNUS YEAR: ________________
All Pledge Balances Due By December 15, 2011. April 1st Is Ticket Priority Deadline!!
GIFT INFORMATION (See Gift Levels Table on page 22 of this brochure)
TOTAL PLEDGE FOR 2011: $ ___________________________
❏ CHECK ENCLOSED: AMOUNT $ ____________________ ❏ MC ❏ VISA ❏ AMEX
CHARGE TO MY:
CREDIT/DEBIT CARD #: _________________________________________________________
EXP. DATE: ___________________
AMOUNT CHARGED: $ ________________________
❏ AUTOMATIC BANK DRAFT* *When choosing BANK/CREDIT/DEBIT CARD DRAFT please complete the form on the reverse side of this card.
❏ YES
❏ NO
SEND ECU PAYROLL DEDUCTION FORM:
MATCHING GIFT FORM ENCLOSED:
SIGNATURE: __________________________________________________________________
THE PIRATE CLUB THANKS YOU FOR YOUR CONTINUOUS SUPPORT.
❏ YES ❏ NO
Join online at www.ecupirateclub.com 35