Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Emergency Contact Name *

Please Notify the Name Entered of Your Selection for Awareness

First Name

Last Name

Emergency Phone *

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Would You Like to Add Someone to Your Membership

Yes

No

Secondary Member Name

Please Advise the Name Entered to Submit Application

First Name

Last Name

Membership Agreement *

I understand that to guarantee my membership stays continuous with no interruptions or change of benefits, I must be paid in full one month (30 days) prior to my yearly contract’s expiration date. I have received a copy of the membership application and agreement and understand and agree to adhere to and abide by the Aphelion Cigar Lounge membership rules and regulations as amended from time to time. Aphelion Cigar Lounge reserves the right to suspend membership privileges until all amounts of past due charges are settled. I hereby acknowledge that all dues, fees and charges for tobacco, merchandise and services at Aphelion Cigar Lounge together with applicable taxes or similar charges that are not paid upon receipt, will be billed on a monthly basis. I further certify that the credit card listed herein is issued to me and agree that all disputes on the credit card account relating to Aphelion Cigar Lounge will be brought to Aphelion Cigar Lounge attention within 30 days of any transaction. I hereby agree to keep a valid and approved credit card on file with Aphelion Cigar Lounge at all times.

Yes, I DO agree to abide by the terms established

No, I DO NOT agree to abide by the terms established

Date

MM

DD

YYYY