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Capitol Hill Club
APPLICATION FOR INDIVIDUAL MEMBERSHIP
Date:
*
Date and time
Calendar
Now
I hereby apply for Capitol Hill Club membership in the following category:
*
Junior Associate Ages 21-25: Initiation Fee $1000, Monthly Dues $48, Quarterly Food/Beverage Minimum $105
Junior Resident 26-28: Ages 26-28 Initiation Fee $1300, Monthly Dues $72, Quarterly Food/Beverage Minimum $120
Junior Resident 29-31: Ages 29-31 Initiation Fee $1750, Monthly Dues $80, Quarterly Food/Beverage Minimum $120
Resident 32: Initiation Fee $2300, Monthly Dues $108, Quarterly Food/Beverage Minimum $175
Resident 33: Initiation Fee $2500, Monthly Dues $120, Quarterly Food/Beverage Minimum $175
Resident 34: Initiation Fee $3500, Monthly Dues $132, Quarterly Food/Beverage Minimum $210
Resident 35 & Over: Initiation Fee $6000, Monthly Dues $171, Quarterly Food/Beverage Minimum $250
Government: Individuals employed by the federal government. Initiation Fee $1750, Monthly Dues $88, Quarterly Food/Beverage Minimum $250
Non-Resident: . Please include payment for the initiation fee and first year’s annual dues. Initiation Fee $2500, Annual Dues $650
*Non- Residents must not have an office or residence within 75 miles of Washington, DC.
Full Name with Title (Mr./Ms./Mrs./Dr./Hon.) :
*
Mr.
Ms.
Mrs.
Dr.
Hon.
Preferred Name on Membership Card:
Home Address:
*
City, State, Zip:
*
Home/Cell Phone Number:
*
(
)
-
First three digits
Second three digits
Last four digits
DOB:
*
Date and time
Calendar
Now
Business/Employment:
*
Name of Employer
Is this a federal position:
Yes
No
Business Address:
*
City, State, Zip:
*
Business Telephone Nubmer:
*
(
)
-
First three digits
Second three digits
Last four digits
Primary Email Address:
*
E-mail Address to receive copy of E-Statements:
*
Send correspondence to:
*
Home
Business
I would like a membership card for my spouse:
Spouse Full Name & Email Address:
Spouse Full Name & Email Address:
Spouse DOB :
Date and time
Calendar
Now
Proposed by (Printed Name of CHC Member):
Member #:
Seconded by (Printed Name of CHC Member):
Member # :
Upload Confirmation of Sponsorship:
Upload file
Upload Confirmation of Sponsorship:
Upload file
Have you ever been a member of the Capitol Hill Club? :
*
Yes
No
Yes/No
Please provide a brief biography.:
*
Payment Type:
*
Credit Card
Check
ACH
Select your payment type
Card Type:
*
(non-specified)
Visa
Mastercard
AMEX
Discover
Card Holders Name: :
*
Enter Credit Card Information:
*
Card Number, Exp, Security Code *Amex CVV s 4 digits on the front of the card**
Billing Address:
*
Email address to receive copies of monthly statements :
*
Multiple choice:
*
I authorize the Capitol Hill Club to make a one-time charge to the credit card listed above.
I authorize the Capitol Hill Club to make a recurring monthly charge to the credit card listed above.
Security code:
*
Enter security code:
300 First Street, Southeast • Washington, DC 20003 • www.capitolhillclub.org