Seattle Social Club

Kali Gurl National Secretary

Dutchess President

Just Blazye Sgt@arms

TwoStep

Hi Sidittee

JuiCee

Member Application

Information

Name: (required)

Current Address: (required)

State and Zip: (required)

Date of birth (required)

Phone: (required)

City: (required)

Email: (required)

Employment Information

Current employer: (required)

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How Long?:

Position:

Employer Address

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Emergency Contact Information

Name of a relative not residing with you: (required)

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References

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Nickname: (required)

Signatures

I authorize the verification of the information. I have received a copy of this application.

Type signature of applicant: (required)

Date: