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Alumni Membership Enrollment Form |
Upon completion, please fax to: 212.986.9543 or mail to: 6 East
44th Street New York, NY 10017 with credit card information included.
Date of Birth: ____/____/____ Cornell ID:________________________Soc.Sec.
#:_______________________________
o
Mr. o
Mrs. o Miss o
Dr. Name:__________________________________________________________________
Last First Middle
Undergraduate
College/School:_____________________________________________________
Class:_______________
Graduate
College/School:__________________________________________________________
Class:_______________
Home
Address:_________________________________________________________________________________
City:________________________________________
State:_________________________ Zip:________________
Business
Name:_________________________________________________________________________________
Business
Address:_______________________________________________________________________________
City:________________________________________
State:_________________________ Zip:________________
Occupation (Field/Industry):________________________________
Title/Position:________________________________
Status:
o
Active o Retired
Please send mail to: o
Home o Business
Home Phone:_____________________________________ Business
Phone:_____________________________________
Fax Number:__________________________________
E-Mail:_______________________________________________
Spouse
Name:_______________________________________________________________________________
Last First Middle
Children (Names and Year of
Birth):_____________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
o
This application is for myself,
as described herein. o
I wish to have signing privileges for my spouse ($150 annually).
In view of my place of residence and employment (see Club definitions of
Resident, Suburban and Non-Resident in member information), I apply for:
o
Resident o
Suburban o
Non-Resident
I understand that you may verify the information on this
application, including requesting reports from consumer reporting agencies. I
hereby make application for membership in The Cornell Club-New York and agree
to comply with the by-laws and house rules of the Club and to pay bills when
due.
Signature of
Applicant:_________________________________________________________
Date:__________________
Payment of Membership Dues:
I understand that once this application for membership is approved, I will
be billed for the initiation fee (a non-refundable deposit) and the quarterly
dues for each quarter, unless I state that I would prefer annual billing. The
club operates on a fiscal year (7/1-6/30).
Initiation Fee:__________________________
Quarterly Dues Payment Plan:__________________ Annual Dues Payment
Plan:____________________
Signature:______________________________ Date:______________________
Cancellation of Membership
:
SHOULD I WISH TO TERMINATE MY MEMBERSHIP, I UNDERSTAND THAT I AM
RESPONSIBLE FOR ALL DUES AND CHARGES THROUGH THE CURRENT QUARTER. I UNDERSTAND
THAT ALL RESIGNATIONS MUST BE IN WRITING AND DELIVERED EITHER IN PERSON, OR
SENT CERTIFIED OR REGISTERED MAIL. SHOULD I WISH TO REJOIN THE CLUB, THERE
WILL BE A REINSTATEMENT CHARGE. Initials: _______
Electronic Funds Transfer:
I authorize my credit card to be charged for my membership dues payment by
the method indicated below and posted to my account.
Credit Card Type:__________________Card
#:__________________________________Exp.Date:______
I understand that the membership dues will be $______________________ and
will be charged to my credit card on the last week of each quarter or fiscal
year beginning:__________.
I request that my applicable club fee be automatically deducted from the
above account for THE CORNELL CLUB NEW YORK. This automatic debit remains in
effect until I can cancel my membership in writing and return my membership
card in conformance with the House Rules and Regulations.
MEMBER SIGNATURE:_________________________________________DATE:_______________________________