PICAYUNE TOUCHDOWN CLUB

MEMBERSHIP APPLICATION

NAME: _________________________________________________________________

ADDRESS: _______________________________________________________________

_______________________________________________________________

HOME PHONE: _____________________ WORK PHONE: ______________________

CELL PHONE: _______________________

EMAIL ADDRESS: _________________________________________________________

DATE OF APPLICATION: _________________________

APPLICANT SIGNATURE: ___________________________________________________

                  AMOUNT DUE:

MEMBERSHIP FEE             $25.00 ______

PREFERRED PARKING PASS ADD $25.00 (OPTIONAL) $25.00 ______

MAROON TIDE TD CLUB T-SHIRT $10.00 (OPTIONAL) $10.00   ______

(CHOOSE A SIZE) S__ M__ L__ XL__ XXL__ XXXL__

TOTAL DUE     ______

*Membership expires on June 30 of the following year.

*Please make checks payable to Picayune Touchdown Club.

*Preferred (Reserved) Parking Passes are available on a first come first serve basis.

PAID BY: CASH

CHECK#     RECEIVED BY:           DATE: