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First Name *

Middle Initial

Last Name *

Birth Date
(MM/DD/YYYY)

Gender Male Female

Second Applicant: First Name

Second Applicant: Middle Initial

Second Applicant: Last Name

Second Applicant: Birth Date
(MM/DD/YYYY)

Second Applicant: Gender Male Female

Third Applicant: First Name

Third Applicant: Middle Initial

Third Applicant: Last Name

Third Applicant: Birth Date
(MM/DD/YYYY)

Third Applicant: Gender Male Female

Fourth Applicant: First Name

Fourth Applicant: Middle Initial

Fourth Applicant: Last Name

Fourth Applicant: Birth Date
(MM/DD/YYYY)

Fourth Applicant: Gender Male Female

Fifth Applicant: First Name

Fifth Applicant: Middle Initial

Fifth Applicant: Last Name

fifth Applicant: Birth Date
(MM/DD/YYYY)

Fifth Applicant: Gender Male Female

Home Street Address *

Apartment Number

City *

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Zip Code *

Home Phone *

Emergency Phone *

Sponsor

Email Address *

Sponsor Phone Number

Business / Employer

Buisness Position

Buisness/Employer 2

Business Position 2

Have you been convicted of a felony? Yes No*

Joining as Prime Fitness/InTune Member through Lilly, Old National Bank? Yes No

Please list number of all Prime/In Tun eligable family member

Volunteer Committees

Accounting / Finance Social Events Marketing Membership Orientation Building & Grounds Long Range Planning / Fundraising Tennis Fitness Aquatics

For Office Use Only
Has applicant been a member before? ________. If so when___________________________________________ Membership Type ____One Adult ____One Adult Household ____Senior Adult >65 ____Two Adults ____Two Adult Household ____Senior Two Adult >65 ____Prim Fitness/InTune Orientation__________ Sponsor Forms___________ Join Date___________ Reason for Joining_____________________________________ Notes_______________________________________________ .___________________________________________________ .___________________________________________________ By (Board of Managers Signature) ______________________________________ Date_________ Follow up phone call date________________________________ Comments ____________________________________________________ ____________________________________________________

Application Agreement
I hereby give my permission to The Riviera Club for any necessary investigation or verification of the above information. I understand that the information above will be held in confidence and further understand that any falsification or omission on this application is grounds for denial of application or revocation of membership. I understand that membership is not transferable and that the entry fee and dues are non refundable. If accepted, I agree to abide by all rules and regulations of The Riviera Club. Signature__________________________________________________ I Agree I Don't Agree*

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