Pontotoc Country Club

P.O.Box 1477

Pontotoc,Ms. 38863

662-489-1962 FAX:662-488-9803

I hereby make application for ( ) Resident ( ) Non-Resident membership in your

club,and,if elected, agree to abide by its constitution, by-laws, rules and regulations.

PLEASE PRINT:

Date: ____________

Name: __________________________________________________ Date of Birth: __________________

Residence Address: ____________________________________________________________________

Mailing Address:________________________________________________________________________

Home Phone: _____________________ Business Phone: _________________________

Cell Phone: _______________________ E-Mail: __________________________________

Occupation: __________________________________ Marital Status: ____________________________

Immediate Family (Name $ Date of all Members) _______________________________________________

________________________________________________________________________________________

Do they play golf? _______ Tennis? _______ Swim? _______

Please list club, fraternal, and college affiliations: _____________________________________________

________________________________________________________________________________________

References: Name:_____________________________ Name:_________________________________

Address:___________________________ Address:_______________________________

Sponsors (Must be Current Members of Pontotoc Country Club)

Signature: __________________________________ Print Name: ____________________________

Signature: __________________________________ Print Name:_____________________________

Applicant Signature: _______________________________________________

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Office Use Only: Date Received: ___________

First Approval:____________ Second Approval: ____________