Welcome to The Edgewood Club

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2012 Member On Line Payment Form

2012 Grandfathered (55+ Couple) Membership $525

*Required Fields

Members Name*

Street Address*

City*

State*

Zip*

Email Address*

Phone*

PAYMENT OPTIONS FOR 2012
Option A – Payment in Full
Option B – Quarterly Payments with Credit Card Only, plus a $25 processing fee
Please Make Your Selection Below*

OPTION A – Payment in Full

$425: Pay in Full before January 31

$450: Pay in Full after January 31 thru February 29

$475: Pay in Full after February 29 thru March 31

$500: Pay in Full after March 31 thru April 30

$525: Pay in Full after April 30

OPTION B – Quarterly Payments

The $25 processing fee will be applied to first
payment (credit cards processed January 1, April 1,
July 1 & October 1)

$425: Quarterly Payments before January 31

$450: Quarterly Payments after January 31 thru February 29

$475: Quarterly Payments after February 29 thru March 31

$500: Quarterly Payments after March 31 thru April 30

$525: Quarterly Payments after April 30

Name on card*

Credit Card Number*

Exp. Date
valid thru 10.31.2012*

Card type*

Credit Card Billing Address (only if different than listed above)

Street Address

City

State

Zip

As the credit card holder, I hereby authorize The Edgewood Club, to charge my credit card for the selected membership category and future fees verbally approved by me. *