Request Information

First Name:*
Last Name:*
Address:*
City:*
State:*
U.S. ZIP code:*
Phone:*
E-mail:*
How did you hear about us?:*	Word of Mouth Related to a Current Member Attended Event/Saw Facilities as Guest Other - Please describe below
Date of Birth:	(For Membership Pricing)
If yes to 2nd option, list Member Name & Relationship:
If yes to 4th option, please describe in box:
Please type the name of your Primary Sponsor:*	(must be a current Erie Club Member)