Membership

Box 55 Association Application

Complete all required fields. Application records, identification, and supporting information are restricted to administrators.

I. Personal information

First name*Middle nameLast name*Alias (if any)Previous first namePrevious last namePresent street address*Address line 2City*State / province*Postal / ZIP codePrevious street addressPrevious address line 2Previous cityPrevious state / provincePrevious ZIP codeMobile phone number*Mobile phone carrier*Date of birth*SSN#*Place of birth*

Sex* Male Female

Civil status* Single Married

Driver's license #*Driver's license state*Upload driver's license or state ID*JPEG, PNG, WebP, or PDF · 10 MB maximum.

II. Personal information (continued)

Emergency contact first name*Emergency contact last name*Relationship*Emergency contact phone*Emergency contact street address*Emergency address line 2Emergency contact city*Emergency contact state*Emergency contact ZIP codeEmployer*Enter “Retired” or “Unemployed” when applicable.Position held*Enter “Retired” or “Unemployed” when applicable.Why are you interested in joining Box 55?*

Do you have social media?* Yes No

III. Criminal history and background release

Have you been apprehended, charged, or convicted for a crime in violation of a law?* Yes No

If yes, provide place, date, and violation details*List and describe any traffic infractions or motor vehicle collisions*

IV. Application / background fee

A non-refundable $100.00 application and background fee applies. Enter the email address where the QuickBooks invoice should be sent.

Invoice email address* I have read the background-check authorization and agree to the background and motor-vehicle-record review described by this application.*Signed date*

Signature*

Protected records

Membership Applications

Available only to administrators.