Membership Application

This is the MEMBERSHIP APPLICATION for the Charlotte Chapter of PrimeTimers®. Please complete all the fields shown as 🌈🌈🌈 {required}.
Then "SUBMIT" the Registration Form and check at the TOP to be sure it went through {or has information missing}.
Prior to or After this form is submitted, continue to the On-Line Payment tab and submit the payment for the selected membership timer period. Payment should be received within 7 days of on-line application.

Date of Application 🌈🌈🌈

Your Full Name {First, MI, Last}: 🌈🌈🌈

Address 🌈🌈🌈

Birth Date {mm/dd only} 🌈🌈🌈

Your Preferred Email 🌈🌈🌈

Preferred Phone Number 🌈🌈🌈

Is It OK To Call At This Preferred Number? 🌈🌈🌈
Yes
No

Membership Dues By Date Joined/Paid: 🔴Select ✅ ONLY One 🔴

New Member Membership: Jan, Feb, Mar: $50.00

New Member Membership: Apr, May, June: $38.00

New Member Membership: Jul, Aug, Sept.: $26.00

New Member Membership: Oct, Nov, Dec.: $14.00

Have you ever been convicted of a felony? You must state YES or NO 🌈🌈🌈

If the reply is YES, please give details and dates of the event/felony

By signing and submitting this application for membership, you certify that you are at least 21 years old, self-identify and present yourself as a gay or bisexual man, subscribe to PrimeTimers® or Charlotte's purpose of socialization and fellowship in a safe and respectful environment, and agree to comply with Chapter operations, policies and procedures.

SIGNATURE OF APPLICANT: By placing NAME and DATE in this box you indicate your agreement and that serves as your signature. 🌈🌈🌈