Poogle Room

Membership Application

I hereby apply for Poodle Room membership. If accepted, I agree to be bound by the rules of the club.
Please note that all sections must be completed in order for this application to be submitted to the committee. All information shall be treated in confidence.

Fields marked with an * are required

First Name *

Middle Name *

Last Name *

Address *

Country *

City *

ZIP *

10 of 10 Character(s) left

Driver's License Number

Email *

Mobile *

Date of Birth *

Member Referral (Optional)

Occupation & Company

Job Title *

Company *

Industry *

Place "NA" if you don’t want to provide it

Other

Additional business, or personal sites you would like to share.

Business website

How did you hear about us?

Fun fact Tell us something unique about yourself

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Photo: PDF, DOCX, PNG, JPG: *

Do you want an individual membership or significant other membership?

Name *

Middle Name *

Last Name *

Date of Birth *

Driver's License Number

Email address *

Phone Number *

Occupation & Company

Job Title *

Company *

Industry *

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