PLEASE COMPLETE THE FOLLOWING IN CAPITALS
TITLE DATE OF BIRTH

PERSONAL INFORMATION
FIRST NAME
SURNAME
ADDRESS
POSTAL/ZIP CODE
COUNTRY
CONTACT NUMBERS

SPOUSE'S NAME
SPOUSE'S DATE OF BIRTH
ANNIVERSARY DATE
CHILD'S NAME
CHILD'S DATE OF BIRTH
CHILD'S NAME
CHILD'S DATE OF BIRTH
COMPANY NAME
BUSINESS TITLE/ POSITION
ADDRESS
POSTAL/ZIP CODE
COUNTRY
CONTACT NUMBERS
E-MAIL ADDRESS
 
MY PREFFERED MAILING ADDRESS IS
HOME ADDRESS BUSINESS ADDRESS E-MAIL ADDRESS

ARE YOU A MEMBER OF ANY OTHER SUCH PROGRAMME?
YES NO

IF YES, PLEASE GIVE DETAILS

ANNUAL MEMBERSHIP FEES
ROOM MEMBERSHIP DINING MEMBERSHIP
RESIDENT IN INDIA Rs. 500 + 12.36% Rs. 5000 + 12.36%
OTHERS $ 25 + 12.36% $ 125 + 12.36%
 
1. Cheque/ Draft No. Dated
  in favour of
2. 2. Please write your temporary membership number on the reverse side of the cheque/draft


Please charge my membership on my credit card
VISA MASTERCARD AMEX DINERS
Credit Card No. Expiry Date
Fee Rs. US$
 
I have read and accepted the terms and conditions of Preferred at The Park.

DATE