Make your own free website on Tripod.com

TheNegrenseMountaineer

MEMBERSHIP APPLICATION FORM

HOMEPAGE
THE CLUB
CLUB HISTORY
THE CLIMBERS & THE MOUNTAIN
BASECAMP NEGROS
SUMMIT NEWS
CALL UP THE PEAK

 

MEMBERSHIP APPLICATION FORM

 

DATE____________________

RECEIVED BY:

 

_________________________________

NAME

 

 

SEX

BIRTHDATE

ADDRESS (HOUSE NO./ STREET/  )

 

 

BARANGAY

 

CITY /  MUNICIPALITY (TOWN)

POSTAL CODE

TEL. NO.

 

 

EDUCATIONAL DEGREE

PROFESSION

 

 

ID PHOTO

NAME OF OFFICE

 

 

WORKPLACE / OFFICE  ADDRESS

 

 

 

 

TEL.NO.

 

 

 

 

 

NAME OF SCHOOL (IF APPLICABLE/ STUDENT)

 

 

SCHOOL ADDRESS

 

 

 

TEL.NO.

CLIMBING EXPERIENCES:

LIST OF MOUNTAINS /PEAKS CLIMBED

 

LOCATION

 

DATE (S) OF ASCENT

 

REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN CASE OF EMERGENCY, CONTACT

(NAME OF PERSON)

 

CONTACT ADDRESS

TEL. NO.

 

BLOOD TYPE:  (    )

 

CERTIFICATION

THIS IS TO DULY CERTIFY that I, the undersigned, have hereunto provided the aforementioned information to the best of my knowledge and belief.

 

 

 

 

_________________________________________________       ________________

SIGNATURE                                                                                        DATE

 

NMC USE ONLY

APPLICATION HAS BEEN

 

(    )   APPROVED

 

(    )  DISAPPROVED

 

BY:_______________________________

MEMBERSHIP REGISTRATION PAID:

O.R. NO._______________DATE_______

 

 

Enter content here

Enter content here

Enter supporting content here