Phlock of South Jersey    Membership Application

Date _________________

Name __________________________ Spouse’s Name _________________

Address __________________________________

City ______________________ State ____________ Zip ______________

Phone (        )____________________ Email _________________________

Date of Birth ___/___/___ Spouse’s Birth Date ___/___/___ Anniversary ___/___/___

Your Occupation _____________________ Spouse's ____________________

How Did You Hear About the Phlock? __________________________________

_________________________________________________________

Child's Name _________________________________ Birth date ___/___/___

Child's Name _________________________________ Birth date___/___/___

 I would be interested in helping with club events

MEMBERSHIP DUES         Phlock of South Jersey
Single   $15.00/Year
Couple  $20.00/Year
Family  $25.00/Year (children under 21)
Sponsoring   $75.00/Year

I am enclosing ________________ for a _________________ Membership

The Phlock of South Jersey is a Not-For-Profit Social Club in South Jersey. Your membership fee and

any contributions made to the Phlock of South Jersey are not deductible as a charitable contribution

for federal income tax purposes. To join the Phlock print and complete this form and include a check or

money order to:

Phlock of South Jersey - Membership Director
℅ Pat Iacovelli
201 Woodland Ave RR #40
Blenheim, NJ 08012