Surrogate Member
Application:
Please
print this form, complete and send to:
1211
Island Drive, Lummi Island, WA 98262.
Renter's
Name: ______________________ Homeowner's Name: ___________________
(please print)
Address:
________________________________________________
Names
of Others Residing in home: _____________________ , _____________________
,
_____________________ , _____________________ , _____________________
I
wish to participate as a surrogate member of Lummi Island Scenic Estates
Community Club and request that my family and I be extended the privileges
of membership.
I
understand that we must comply with the published
rules and regulations of the Club and that the Board may withdraw
the privileges of membership if we fail to honor those guidelines for the
use of the Club facilities. I understand that membership terminates
automatically when we move out of the Estates.
Renter's
Signature: _______________________________ Date: ____________________
Homeowner's
Signature: __________________________ Date: ____________________
For Office Use
Only:
Approved:
__________________________________ Date: ________________________
Lot
#: _______ Division # _______ Block # (if applicable): _______
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