Name_________________________________________________________

I'm a Member of_________________________________________Golf Club

Golf Club Phone Number__________________________________

My Birthdate________________________________

Home or Preferred Mailing Address:

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________


Winter Address, If Applicable:

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________


Home Phone______________________________

Home Fax________________________________

Cell Phone________________________________

Office Phone______________________________

Office Fax________________________________

Email_____________________________________

Website___________________________________

Please enclose this Application and a $100 dues check, payable to "Bill Hirsch", & remit to same @
27010 Grand Central Pkwy, Suite 2C • Floral Park, NY • 11005-1102

Thank you!