Student Membership Enrollment Form

Student 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:_______________________________