Lake Wisconsin Country Club                    N1076 Golf Road         Prairie du Sac, WI 53578                Pro Shop (608) 643-2405           Office (608) 643-4554

MEMBERSHIP APPLICATION LAST NAME________________FIRST NAME____________SPOUSE_______ ADDRESS______________________________TELEPHONE______________ CITY________________STATE________________ZIP___________ EMAIL ADDRESS_______________________________________________ TYPE OF MEMBERSHIP DESIRED (See dues structure): CHECK ONE:  SINGLE_____COUPLE_____FAMILY_____ CHECK ONE:   YOUNG ADULT_____                    TRANSITION ADULT_____                     REGULAR______                     SOCIAL_____                     CORPORATE_____ IF APPLYING FOR YOUNG OR TRANSITION ADULT MEMBERSHIP, STATE BIRTHDATE_____ CHILDREN'S NAMES AND AGES:_________________________________ APPLICANT PLEASE NOTE All new members must purchase a membership certificate and  pay a certificate assessment. The cost of a membership certificate is $100 plus tax (5.5%) and the certificate assessment is up to $300 plus tax depending on the membership. Please call Leon Kleinert at 608-643-4554 for the exact amount. These initiation fees are due in addition to annual dues and assessments with this application. Membership priveleges begin immediately, but are subject to membership confirmation by the Board of Directors. SIGNATURE OF APPLICANT(S)__________________________________ Referral (by 2 members not on the Board of Directors)     SIGNATURE OF CLUB MEMBER___________________________________     SIGNATURE OF CLUB MEMBER____________________________________ My membership was sponsored by_________________________________ Please indicate which of the following services you will require:     Cart storage_____     Season golf car rental_____     Locker rental____     Towel service_____     Computer handicap_____     Boat slip____     Trail fee_____                                       *****OFFICE USE ONLY***** DATE OF BOARD APPROVAL_______SIGNED_______________________________________________________