Leather Order of The Midlands P.O. Box 7364, Columbia Sc 29202-7364
PERSONAL INFORMATION
NAME _____________________________________ DATE OF BIRTH _____________
ADDRESS _________________________CITY_____________STATE ___ZIP ________
PHONE (____)____-_________ EMAIL______________________@________________
MEMBERSHIP REQUESTED: FULL ____________ ASSOCIATE ____________________
CLUB ASSOCIATIONS______________________________________________________
GENERAL INFORMATION
Reason(s) for Joining:_________________________________________________
In the event of a medical emergency do you have any physical or medical condition that the club or its members should be
aware of? Please List: _______________________________________________________________________
Emergency contact person(s)_______________________ Phone ______________
DUES INFORMATION

Upon acceptance as a full member, dues are: Full Membership is $64 per person if paid annually in advance, or $8 monthly.
Full Membership Applicants: The Applicant will spend three (3) months (90 days) in a Pledgeship period so that he or she can get to know the club members and its purpose. Once your membership has been approved, yearly dues are incurred and payable each August at the club meeting. Full members in good standing have voting privileges and may hold office.
Associate Membership Applicants: Lifetime Associate Membership dues of $35.00 are incurred and payable upon approval of your application. Associates in good standing maintain the right to wear an associate's patch, but do not have the right to vote or hold office.
DUES ARE SUBJECT TO CHANGE WITHOUT NOTICE
DISCLAIMER

Membership is open to all persons regardless of race, color, creed, gender, sexual orientation, or who is at least 21 years of age. By signing this application, I certify that I am at least 21 years of age and that the information supplied is true and accurate. I will not hold Leather Order of The Midlands, its members of associates liable for anything incidental or consequential and will abide by all club by-laws and rules of conduct. Failure to comply will be terms for removal from the club.

Signed:_______________________________________ Dated: _________________
CLUB USE ONLY

MEMBER SPONSORS (2 FULL MEMBERS REQUIRED)
1.)_________________________________2.)________________________________
RECEIVED:________ APPROVED:________ DISAPPROVED: _______ DATE:_________

(This application is currently subject to revision)