Last Name First Name __

________________________ __________________________

RESIDENCY:

Bethlehem Resident __________ Non-Resident __________

REMINDER: To qualify for Resident rate applicants must be full time Bethlehem residents

OR pay property taxes to the town of Bethlehem.

MEMBERSHIP:

Membership Type: MW Single_____ Single______ Couple_____

Family_____ College Student_____Junior______ 10 Play_____

Interested in Twilight Leagues YES___ NO___

ADDRESS:

Mailing Address:

Street________________________Town_____________________State___________Zip______

Phone__________________ Work Phone______________________

E-mail Address__________________________________________________

(Please provide as we will correspond using email during the season)

Winter Mailing Address ________________________________________

Town ____________________________

State____________ Zip___________ Phone_______________________

PAYMENT:

Method of Payment Cash___ Check___ Credit Card___

TOTAL AMOUNT PAID $ _________________ Date paid____________

If you use your Visa or MasterCard please complete and SIGN below

Account # ________________________________________________

Exp.Date ____________

Signature __________________________________________

MAKE CHECKS PAYABLE TO: Bethlehem Country Club

MAIL TO: Bethlehem Country Club

Attn. Dave Pilotte

PO Box 445

Bethlehem, NH 03574

QUESTIONS:

603-869-5745 (April 15th – October 31st)

603-444-3419 (November 1st – April 14th)

Last Name ________________________ First Name __________________________