KREWE OF FORT BROOKE, INC.

5005 S ELBERON ST. TAMPA, FL 33611

813-835-5034

APPLICATION FOR MEMBERSHIP

NAME __________________________________________DATE__________________

HOME ADDRESS________________________________________________________

CITY ________________________ STATE______________ ZIP__________________

HOME PHONE _______________________________WORK PHONE______________

DATE OF BIRTH __________________ OCCUPATION ________________________

DRIVERS LICENSE _________________________________STATE _____­­­­_________

EMPLOYER ____________________________________________________________

EMPLOYER ADDRESS, STATE ZIP ________________________________________

HOBBIES ______________________________________________________________

E-MAIL ADDRESS_______________________________________________________

NAME ADDRESS OF NEAREST RELATIVE _________________________________

________________________________________________________________________

SPOUSE ______________________________

EMPLOYMENT & PHONE # ________ ________________________________________________________________________

MEMBER WHO IS YOUR SPONSOR _______________________________________

I AGREE TO SAME TO SAVE AND HOLD HARMLESS THE KREWE OF FORT BROOKE, INC. FROM ANY AND ALL LIABILITY ARISING FROM DISCLOSURE OF INFORMATION BY ANY LAW ENFORCEMENT AGENCY OR OTHER ENTITIES THAT MATERIALLY AFFECT THE MEMBERS OF THE KREWE.

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APPLICANT SIGNATURE

MAKE CHECK PAYABLE TO THE KREWE OF FORT BROOKE, INC. FIRST YEARS DUES ARE $500. CHECK MUST BE ATTACHED OR APPLICATION WILL NOT BE CONSIDERED.

ANY QUESTIONS CALL: DICK KIRCHEN WK: 207-5030 HM: 835-5034

TODD BRAY WK: 264-0440 HM: 839-0345