The “Ballroom” Inc.
A Private Social Dance Club
2010
Membership Application
Membership Dues Are Per Person
Print Clearly
New Member $30.00 ____ Renewal $20.00 ____ Membership #______
Name_______________________________________Birthday:Month_____Day____
Name_______________________________________Birthday:Month_____Day____
Mailing Address_________________________________________________________
City_________________________________________State_________Zip___________
Phone:_________________ Email Address____________________________________
Rules: 1. Membership is restricted to individuals 21 years old or older.
2. Membership cards are not transferable and may be revoked if loaned.
3. Membership may be revoked at the discretion of the Executive Board
4. Annual membership dues are from January 1 – December 31.
5. New annual membership dues are $30 per person
6. Renewal annual membership dues are $20 per person
7. All Memberships expire December 31st each year.
Note: On special occasions the Ballroom will be closed to Members, their Family & Guest.
I agree to the membership rules & requirements outlined above and I certify that the information included on this application is true and correct and that the applicant(s) listed above are over the age of 21.
______________________________________________ _________________________
Signature Date
The “Ballroom” 465 South Nova Road, Ormond Beach, FL 32174
Club use only:
Method of Payment:
Check #_________Cash_______ Amount Received $____________ Date Received _____________By_____
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