Membership Application: Last Name *: First Name *: Middle Name: Address: City: State: Zip Code: Home Phone: Cell Phone: E-mail Address: Date of Birth: Height: Weight: Hair Color: Eye Color: Race: Sex : Male Female Drivers License: Drivers License Exp:: Drivers License State:: CHL Number: CHL Issue Date: CHL Exp.: Type of Membership   1 Year Platinum Membership - $385.00 plus Tax   1 Year Regular Membership - $365.00 plus Tax Spouse Membership   No Spouse   Spouse Membership - $192.50 plus Tax Comments or Questions Referred By   Radio   Flyer   Newspaper   Friend   In Store   Jerry   Bob