Primary Member Full Name (First & Last): *

Home Club Name: *

Membership #: *

Spouse Full Name (First & Last): *

Primary’s Birthday: *

Spouse’s Birthday: *

Street Address, City, State, Zip: *

Home Phone: *

Work Phone: *

Cell Phone: *

Primary’s Email Address: *

Spouse’s Email Address: *

Wedding Anniversary: *

Date Joined Home Club: *

By upgrading my membership to Palmer Advantage Platinum I understand I am subject to the terms and conditions of Palmer Advantage Platinum, which are available through your Club Membership Office and on this website. *

I understand there will be a one time $500 Enrollment Fee that will be on my next monthly club statement. *

I understand that the monthly fee will be $20 and will appear on my monthly club statements. *

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