Membership Request Applicant's Name * First Name Last Name Applicant's Date of Birth MM DD YYYY Gender * Male Female Telephone * (###) ### #### Email Address * Residence * (Town & state that you live in) Career/Profession * My favorite bar or restaurant is... * (Enter name and city) Other social groups I belong to... * I heard about Le Malt Royale from... * Enough about Royale, let's talk about me... * (Where you're from, about your family, likes, dislikes, leisure interests & what you hope to get out of the club) Any questions or comments? Thank you! Your membership request has been submitted. One of our Le Malt Royale membership coordinators will be in touch with you shortly.