Please be sure to fill out each section completely and then sign and date. If you have any questions please e-mail us at info@chicagoleatherclub.org

PERSONAL INFORMATION
Name: _________________________________ Birthday Month: ______ Day: ______

Address: ____________________________________________________ Apt: ______

City: ________________________________________ State: _____ Zip: __________

Phone: (______)_____________ Occupation: _________________________________

Fax: (______)_____________ e-mail address: ________________________________

COMMUNITY INTEREST/INVOLVEMENT…
Current and/or previous club affiliations:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any special skills or talents that you believe CLC would find of interest.
____________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________

What are your reasons for wanting to join CLC?
__________________________________________________________________________________
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How might you be willing to help/support CLC?
__________________________________________________________________________________
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MEMBERSHIP CATEGORY…
I am interested in becoming a:

___ FULL MEMBER ($75.00 dues per year—applicant must live within a 50-mile radius of Chicago. There is a pledge period with a required project and other community support activities.)

___ ASSOCIATE MEMBER ($30.00 dues.)

I am submitting __ cash (no cash except in person please!), a __ check, or __ money order made payable to "Chicago Leather Club" in the amount indicated above. I understand that if my application is not approved, all submitted monies will be refunded to me.

MEMBERSHIP DISCLAIMER…
I certify that I am 21 or older and that the information in my application is true and correct. I understand that CLC is a pansexual organization founded to provide service to the community and outreach within the Leather/BDSM/Fetish community. I agree that should my conduct be deemed inconsistent with the intent and purpose of CLC, that it has the right to revoke my membership at its discretion. I also have the right to withdraw from my association with CLC at any time. I understand that CLC is not responsible for any transactions between myself and any people I may contact through their events, nor may the organization or its membership be held responsible in any way for my statements or actions. By my signature below, I affirm the above and agree to abide by the requirements and any other policies and procedures established by the Chicago Leather Club.

SIGNATURE: ____________________________________ DATE: __________________

SPONSORSHIP…
The signatures of two Full members are required for Pledge applicants, and one Full member for Associate applicants living within the territory (if you are more than 50 miles from the Chicago city center no sponsor is required).

SPONSOR: _________________ MEMBERSHIP #: ___________ DATE: _________

SPONSOR: _________________ MEMBERSHIP #: ___________ DATE: _________

MAIL TO…

CLC, Inc., Membership Secretary, POB 60214, Chicago, IL 60660

OFFICE USE ONLY

Membership #: _____________ Membership Expiration Date: _______________

Date Application Received: __________ Dues Paid: $____________

Check/Money Order #: _________

Pledgeship Start Date: ________ Pledgeship End Date: ________

Pledgeship Extension (# OF MONTHS): _________

Pledgeship Extension End Date: _______________

Chicago Leather Club, Inc.
Membership Secretary
P.O. Box 60214
Chicago, IL 60660

info@chicagoleatherclub.org • www.chicagoleatherclub.org