Khedive Golf Club

Date: _________________________

__________________________       _________________________     ________      _______

             Last Name                                                First Name                        Initial            Suffix

________________________________    _______________________    _____    _________

                Address                                                          City                          State           ZIP

_______________________________                            _____________________________

              Nickname                                                                            Spouse’s Name

_______________________________                           _____________________________

               Phone                                                                                E-mail Address

Shriner: Yes / No                           If No,  Guest of Noble _____________________________

This application should be submitted, along with your dues of $10.00, to the Club Secretary (if a Guest, via your sponsor).  An additional $1.00 should be submitted if you desire "Hole-in-One" insurance.

Please note: The information submitted by you is for the exclusive use of the Club Secretary in the execution of his duties. No dissemination to an outside entity is authorized and will not be condoned.