Membership

USA Unlimited, Inc.

101 North Center Street Hickory, NC 28601

Membership Application

Please complete this application in its entirety and return it to a Member Services representative at the check-in desk.

Membership is only available for individuals twenty-one (21) years of age or older with valid photo identification.

PLEASE PRINT NEATLY & LEGIBLY!

Your Full Name: ________________________________________________ Date of Birth: _____________________

Address: ____________________________________ City: _________________ State: ________ Zip: __________

Email Address: ______________________________________________ Phone Number: _____________________

Membership Agreement:

By accepting membership with USA Unlimited, Inc (the “Company”), the Applicant agrees to be personally responsible for any

and all of his/her guests. Furthermore, the applicant agrees to indemnify the Company and its agents from any and all liability

or loss arising from damage to or destruction of property or injury to persons occurring as a result of the consumption of

alcoholic beverages by the Applicant and/or his/her guests.

Further, by accepting membership with the Company, the Applicant understands that he/she may be filmed and recorded

while visiting with the Company. The Applicant agrees to grant to the Company an irrevocable, perpetual, non-exclusive, fully

paid, worldwide license to use, copy, perform, display, and distribute such recorded information and content and to prepare

derivative works of, or incorporate into other works, such information and content, and to grant and authorize sublicenses of

the foregoing. For the purpose of this agreement, content shall be described as photos, videos and audio recordings made of

the Applicant during his/her visit with the Company, by the Company and its agents.

The Company reserves the right to alter these terms at any time and any alterations shall become effective immediately.

Members will be notified of changes to these terms through the Company’s website, by email or in person at the Company’s

member services check-in desk.

By signing below, the Applicant agrees to these terms of membership. Further, under penalty of perjury the Applicant agrees

that the information provided above is true and accurate.

Applicant’s Signature: ________________________________________________ Date: ______________________

-------- OFFICE USE ONLY -----------------------------------------------------------------------------------------------------------------------------

Form of Identification: Driver’s License Photo ID Card Military Photo ID Passport Other __________

Identification Number: __________________________ Expiration Date: ____________ Issuing Agent: _________

Date of Birth Verified: Yes No Membership Committee Review: Approved Denied

Reason for Denial: ________________________________________________________________________________

Membership Number Assigned: ________________________ Membership Expires: _______________________

By signing below, I acknowledge that I have received my membership card from the Company. I understand the card is property of the Company and

that I must return the card upon request by the Company. I further understand that I am responsible for obeying State law governing my membership.

Applicant’s Signature: ________________________________________________ Date: ______________________