NORFOLK, VA 23517

The undersigned hereby applies for membership in the Mallory Country Club, Inc. and if elected, agrees to abide by its Bylaws, Policies and Procedures. Stock may be purchased by one person or by a husband and wife.

STOCK CERTIFICATE TO BE ISSUED IN THE NAME(S) OF:

(Once the stock is issued, a fee of $25 is required to change the name(s) on the certificate.)

Mailing Address: _______________________________________ Phone(s): ________________

_______________________________________ ________________

E-mail address:____________________________________

Adults Name (As you wish to be called at Mallory)

First Last M/F Employer Work Phone

__________________ ____________________ _______ ___________________ ______________

Dependents eligible to use the club facilities must be in one of the following categories:

1) dependent under age 21 on June 15 of the current year.

2) dependent age 21 to 24 on June 15 of the current year who is a full time student.

3) dependent age 21 or over on June 15 of the current year with a disability (Please include a short description of the situation.)

Name (As you wish to be called at Mallory) birthday age on category

first last (mm/dd/yy) m/f JUN 15 (1,2, or 3)

____________________ ___________________ ___________ _____ _____________ _______

Any other household member is unable to use the Club facilities except as a registered guest.

If parent of applicant is a current MCC member, please give name and membership number:

MEMBERSHIP PROPOSED BY (Signature of 3 current members is required):

name & membership number (print or type) signature date

1) _________________________________________ ___________________________ _______

2) _________________________________________ ___________________________ _______

3) _________________________________________ ___________________________ _______

(A first year member may not propose new members. Each membership may propose only 2 applications per year.)

Enclose $150 Application Fee (non-refundable), payable to Mallory Country Club, Inc. and return to the address printed at the top of the page.

Rev. 01/30/08