Long Beach Century Club

MEMBERSHIP APPLICATION 
 

Name: __________________________________  Spouse’s Name ______________________ 

Address: ___________________________  City: _________________________ Zip_______ 

Home Phone: __________________  WorkPhone: ____________________________ 

Cell Phone: _________________  Fax: __________________  Birthdate: _________ 

Employer/Business: ___________________________ E-mail:___________________ 

Position: _______________________________________________________________ 

High School Attended: ___________________________________________________ 

College/University: ______________________________________________________ 

Name of Nominating Member: ____________________________________________ 

I hereby apply for membership with the Long Beach Century Club and agree to abide by the by-laws of the club upon my acceptance. 

SIGNED: _______________________________   DATE: _______________________ 
 

We the undersigned recommend the above individual for membership. 

1. _____________________________  2)_________________________________

3)_______________________________ 4)_________________________________ 

Prospective members must be nominated by a member in good standing and endorsed by 4 sponsoring members.  Initiation Fee is $100 for new members and $50 for Middle and High School Coaches/Administrators.  New members joining after April will have their dues applied towards the following year as well.