ReStart a Charldine Club [International] Membership

Full Membership $100.00 . Answer all of the questions that apply.
STATUS= I am making this request as a:
PastMember(s) ReStarting.
His First name (the name your intimate friends use.)
His date of birth: Mo/Da/Yr
Her First name (the name your intimate friends use.)
Her date of birth: Mo/Da/Yr
Mailing ADDRESS
City
State Zip
Area Code & Phone #
E-Mail:   Primary  Alternate
E-mail Format:    yourhandle@yourserver.com

Attendance is to certify that you are over 18 years of age, and hold the same philosophy as stated in our open-letter "Governing Views and Philosophy", and you will observe all government rules and regulations.
You also declare that you are seeking this meeting of your own free will as a private-person.
1]. Are you employed or associated professionally with anyone, where-by you are seeking to obtain material and/or information to be used in a profession? (Example; TV, Radio, Newspapers, Magazines, College-studies).
answer_ Yes No
2]. Are you a member of or associated with any government or law enforcement agency, here to entrap or obtain information to be used as part of any investigation?
answer_ Yes No

Enter HIS full legal name here:
Enter HER full legal name here:

Your legal Signature(s)___________________________________________Date___________

Past members who allowed their membership to expire. Enter your old club# if you remember it.
Otherwise enter ' 0000 '  

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