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Columbia House |
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PayPal On-Line Application
Empire Z Membership Application
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| Date of Birth:
E-mail:
Car Information - Select from below Year:
Make:
Model:
| Other: Color: Associate Membership (Wife - Son/Daughter - Significant Other) First Name:
Initial:
Last Name:
| Address: |
City:
State:
Zip Code:
Relationship:
| Home Phone:
Cell/Work Phone:
| Date of Birth:
E-mail:
| Emergency Contact - Optional Information Name of Relative not
residing with you:
| Address: |
City:
State:
Zip Code:
Relationship:
| Home Phone:
Cell/Work Phone:
| Membership Fee & Privacy Policy Membership Fee: Yearly membership is $20.00 per year - due March 1st. Dues are $10.00 after September 1st. Associate Membership Fee: Yearly associate membership is $10.00 per year - due March 1st. Dues are $5.00 after September 1st. Amount Submitted: Privacy Policy: All information submitted on this form will be held confidential by the officers of Empire Z. Your personal information will not be sold or revealed to anyone without your specific permission. I hereby state the above information to be true. Release of Liability I hereby release Empire Z, its officers and members, from any liability due to accident, injury, theft, or any other reason while attending or participating in any and all Empire Z events and/or functions. Membership application is not complete until you have indicated a "Yes" answer to understanding this release and entering a date. I understand and
agree to the above release of liability.
Must Select "Yes" or "No"
Pay your dues On-Line with your PayPal account. Log-in to your PayPal account and make payment to: membership@empirez.com. Indicate in the Remarks section of PayPal that you are making a payment for yearly dues. Be sure to complete and submit this Application so we know who to apply the payment to. You are not a member until your dues are received in our PayPal account.
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