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                                                       Laverne Golf & Country Club

                                                         Membership Application



 Primary Member’s Name: __________________________

Address: ________________________________________

City: _________________ State:______ Zip: ___________

Birth date :( mo/day/year) ________________

Home phone :(_____)__________Email:_______________





Payment Information

□ Annual Membership                     $540.00


Payment Options:

Monthly                                            $45.00

Cart Shed                                         $20.00


** (Monthly payments by bank draft at Security State Bank-Laverne) **

** If not drafting you can write a check, Payment due quarterly, every six months or in full annually



  Please List additional family name(s) that will be on the membership:


 Name:                                                                                  Relationship:

______________________________________________                  ______________

______________________________________________                  ______________

______________________________________________                  ______________



                                     Total Amount Enclosed ____________ 


     Please put Application in green box or take to David Terry’s CPA office

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