Club Membership Registration Form

Village Creek Golf Club Membership
Applicant Information
Name *

First Name Last Name
Phone Number: *

Area Code Phone Number
E-mail
Physical Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address is the same as my physical address *

Yes No
Mailing Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date: *

Month Day Year
Marital Status

Single Married Divorced

Dependents

	Name	Relationship	DOB
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Employment Information
Current Employer: *
Occupation: *
Employer Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Member Reference Information
I do not know any current members
Member 1
Member 2
Member 3

Membership information is below. Please choose the proper membership based on your needs.

***$100 Initiation fee will be assessed on first payment for Regular, Dual Membership, and Junior membership levels

Membership Type	Amount	Detail
Regular	$100/Monthly $1200/Annually	Unlimited green fees & Use of pool and clubhouse for all dependents living in the member’s household.
Junior (Individuals under the age of 30)	$65/Monthly $780/Annually	Unlimited green fees & Use of pool and clubhouse for all dependents living in the member’s household.
Pool/Clubhouse	$400/Annually	Unlimited access to the pool and clubhouse for all dependent living in the member’s household.
Cart Shed Fee	$20/Monthly $240/Annually	Access to store a single golf cart in a provided shed at the golf course

Membership Type *

Regular Junior Pool/Clubhouse Cart Shed
Banking Information
Bank Name: *
Routing Number: *
Account Number: *
Name on Account (if different then applicant)
This completed application form, along with payment of the initiation fee should be returned to:

Village Creek Golf Club
P.O. Box 252
Newport, Arkansas 72112

If you have any questions, please contact Kullen Poe at (870) 217-5458

Legal Statement
I hereby make application for membership in Village Creek Golf Club, Inc. (VCGC) of Newport, AR and agree, if elected, to comply with the by-laws, golf course rules, swimming rules, house rules and such special regulations for members as the Board of Directors may adopt.

I understand that by submitting this application, should my membership be approved, I am making a commitment to maintaining my membership for no less than one annual term (12 months), beginning with the first month that my dues are paid. After this initial term, my membership will continue on a monthly term, until a request to terminate membership is submitted to the board, or membership is terminiated by VCGC due to violating club rules and by-laws. Should membershp be terminated for any reason before the original term is complete, VCGC may be compensated for remaining dues in total.

I also hereby authorize Village Creek Golf Club to draft my account for payment of dues and other fees, provided there are sufficient collected funds in said account to pay the same upon presentation. This authority is to remain in effect until revoked in writing and I agree that if such check is dishonored, whether with or without cause and whether intentionally or inadvertently, the club will be under no liability whatsoever even though such dishonor may result in the forfeiture of membership.
*

I have read, understood, and accepted the above statement.
Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!
Signature *

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Village Creek Golf Club Membership

Applicant Information

Employment Information

Member Reference Information

Banking Information