Resident Member

Regent Club APPLICATION NO:

Metropolis Campus, #73/1, Garudacharpalya,
Whitefield Main Road, Mahadevapura Post,
Bangalore-560 048. www.brigadehospitality.com

Application Recent
passport-size
FOR MEMBERSHIP photograph of
the
Primary Member
MEMBERSHIP VALID UPTO DEC., 2050 to be
PLEASE FILL IN THE BLANKS, USING CAPITAL LETTERS, WHEREVER BOXES ARE PROVIDED, MARK YOUR CHOICE WITH A “a
” pasted here.
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

1. DETAILS OF THE PRIMARY MEMBER

PERSONAL INFORMATION

FULL NAME...................................................................................................................................................................................................................................................................

.DATE OF BIRTH............................/............................./..............................MARRIAGE ANNIVERSARY............................/............................./..............................

FLAT NO:...................................................................................BLOCK..............................................................................NATIONALITY....................................................................

PRESENT ADDRESS....................................................................................................................................................................................................................................................

......................................................................................................................................................................................................................................................................................

TELEPHONE NUMBER (RESIDENCE).............................................................................................................E-MAIL................................................................................................

PROFESSIONAL INFORMATION

PROFESSION / DESIGNATION...................................................................................................................................................................................................................................

COMPANY NAME AND ADDRESS...............................................................................................................................................................................................................................

......................................................................................................................................................................................................................................................................................

TELEPHONE NUMBER (OFFICE).........................................................................................................................MOBILE..........................................................................................

WHERE WOULD YOU LIKE US TO CONTACT YOU? RESIDENCE OFFICE SPECIMEN SIGNATURE

2. DETAILS OF FAMILY (ADD ON) MEMBERS

FAMILY MEMBER # 1

NAME..................................................................................................................................................................................... MALE FEMALE

RELATIONSHIP WITH PRIMARY MEMBER..................................................................(DATE OF BIRTH)............../............../.....................................

Recent
PROFESSIONAL INFORMATION passport-size
photograph of
PROFESSION / DESIGNATION................................................................................................................................................................................. the
Add-On Member
to be
................................................................................................................................................................................................................................... pasted here.

TELEPHONE NUMBER (OFFICE).............................................................................................................MOBILE...................................................

E-MAIL.......................................................................................................................................................................................................................

SPECIMEN SIGNATURE
FAMILY MEMBER # 2

NAME..................................................................................................................................................................................... MALE FEMALE Recent

passport-size
photograph of
RELATIONSHIP WITH PRIMARY MEMBER..................................................................(DATE OF BIRTH)............../............../.....................................
the
Add-on Member
E-MAIL....................................................................................................MOBILE..................................................................................................... to be
pasted here.

SPECIMEN SIGNATURE

FAMILY MEMBER # 3

NAME..................................................................................................................................................................................... MALE FEMALE

Recent
passport-size
RELATIONSHIP WITH PRIMARY MEMBER..................................................................(DATE OF BIRTH)............../............../..................................... photograph of
the
E-MAIL....................................................................................................MOBILE.....................................................................................................
Add-on Member
to be
pasted here.

SPECIMEN SIGNATURE

1. MEMBERSHIP FEE PAID: ...................................................................................................................................................................................................................................

2. DECLARATION

I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS FORM IS TRUE. I HAVE READ THE RULES AND REGULATIONS / BYE LAWS AND CONFIRM THAT I AND THE
OTHER MEMBERS RELATABLE TO MEMBERSHIP WILL ABIDE BY THEM. I ALSO AGREE TO BE ACCOUNTABLE FOR ALL PAYMENTS AND LIABILITIES TO THE CLUB ON MY
BEHALF AS ALSO MEMBERS RELATABLE TO MY MEMBERSHIP.

PLACE:

DATE: SIGNATURE OF THE PRIMARY MEMBER

FOR OFFICE USE ONLY

SCRUTINISED BY CHECKED BY APPROVED BY

MEMBERSHIP CARDS ISSUED:

TYPE OF MEMBER MEMBERSHIP CARD PARTICULARS DATE OF ISSUE

PRIMARY MEMBER

ADD ON MEMBER # 1

ADD ON MEMBER # 2

ADD ON MEMBER # 3

DATA ENTERED BY : FILE NUMBER: