Lakeshore Brewers Guild Membership Application

Organization Name:*

Contact Name:*

Membership Type:*

(select the appropriate classification for your application)

Brewery Classification:*

Affiliated Classification:*

Enthusiast DOB:

Enthusiast T-shirt Size:

Mailing Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Organization Phone:

Contact Phone:*

Phone:

Email:*

Enter Email Confirm Email

Liquor License:*

State of Where Liqour License Issued:*

TTB Brewers Notice #: (If applicable)

THE INFORMATION BELOW WILL BE PUBLISHED ONLINE AND IN SOCIAL MEDIA

Brewery / Retail Address:

Public Phone Number:

Public Email Address:

Website

Facebook:

Twitter:

Instagram:

Brewery Membership cost:

Price:

Brewery In Planning Membership cost:

Price:

Allied Retail Membership cost:

Price:

Enthuisiast Membership cost:

Price:

Credit Card*

Card Details

Cardholder Name