NEW LE SUEUR COUNTRY CLUB MEMBERSHIP APPLICATION FORM
(Application Directions: Step 1.Print this page, Step 2. Complete form, Step 3. Mail form with payment to address below)

NAME: ______________________ D.O.B. ________ SOC. SEC.# _____________

SPOUSE: ____________________ D.O.B. ________ SOC. SEC.# _____________

ADDRESS: ________________________________________________________

CITY: _____________________________ STATE: ______ ZIP: ______________

HOME PHONE: ________________WORK PHONE: ______________________

EMAIL ADDRESS: _____________________________________________

PAYMENT AMOUNT ENCLOSED: _______________________________

PLEASE CHARGE MY CREDIT CARD: # __________________________

SEND PAYMENT TO:
Le Sueur Country Club
Attention: Jerry Carpenter
PO BOX 163
Le Sueur, MN 56058-0163

Please direct any questions to Jerry at (507) 665-6292 or email jcarp@hickorytech.net.