www.charlotteseminoleclub.com                       18723 Silver Quay Drive; Cornelius, NC 28031   

Last Name:                                                    First Name:                                                                

Spouse’s Name (if applicable):                                                                                                    

Home Address:                                                                                                                                

City, State, Zip:                                                                                                                                 

Home #:                                             Work #:                                  Mobile #:                              

E-mail Address:                                                                                                                                

Are you an FSU graduate?                                    If yes, what year:                            

Is your spouse an FSU graduate?                                     If yes, what year:                            

Where do you work?                                                                                                                     

What is your job title?                                                                                                                     

Membership type:  Self ($25.00/year)                              Family ($35.00/year)