PBC Registration

The purpose of this form is to determine if you are qualified to join the fellowship of Clampers. Failure to properly answer the questions may result in rejection. Please answer seriously and with forethought.

Application must be received by April 18th, 2025

PBC Application Form

Registration Fee: $104.00

Applicant Information

First Name *

Please provide your first name.

Middle Name

Last Name *

Please provide your last name.

Street Address *

Please provide your street address.

City *

Please provide your city.

State *

Please provide your state.

ZIP Code *

Please provide your ZIP code.

Phone (Work)

Phone (Home) *

Please provide your home phone number.

Email Address *

Please provide a valid email address.

Name of Wife or Next-of-Kin *

Please provide the name of your wife or next-of-kin.

Additional Information

Place of Birth *

Please provide your place of birth.

Date of Birth *

Please provide your date of birth.

Employer Name and Address

Questions

Do you believe in our Supreme Patron, Saint Vitus? *

Please select an answer.

Would you give a sucker an even break? *

Please select an answer.

Will you respect authority under the silk hat? *

Please select an answer.

Will you temper the Sword of Justice with Mercy? *

Please select an answer.

Will you ever use your Blunderbuss to protect the widow and the orphan? *

Please select an answer.

Reason for joining Clampers? *

Please provide your reason for joining.

Contribution by you or your ancestors to California History? *

Please describe contributions to California history.

Do you have any physical disabilities to be known to the Greybeards?

Sponsor Information

Sponsor Name *

Please provide your sponsor's name.

Sponsor Phone Number *

Please provide your sponsor's phone number.

Date of Membership

Hold Harmless Agreement

PHOTO ID REQUIRED AT EVENT FOR PROOF OF AGE

I, the undersigned, intending to be hereby legally bound, for myself, my heirs, executors, administrators and assigns, waive and release any and all rights and claims for damages I may have against Estanislao Chapter 58, E Clampus Vitus, Grand Council, and their officers, directors, trustees, subcommittees, agents, representatives, and members of the meeting for any and all losses or injuries suffered by me at this meeting.

I understand and agree that medical or other services rendered to me by or at the insistence of any of the above parties is not an admission of liability to provide or continue to provide any such services is not a waiver by any said parties of any right hereafter.

I understand that should I violate the Code of Clamper Conduct that I may be excluded from E Clampus Vitus. $30 CHARGE FOR ALL RETURNED CHECKS

Digital Signature *

By typing your name, you agree to the terms and conditions above

Please provide your digital signature.

E. Clampus Vitus

PBC Registration

PBC Application Form

Applicant Information

Additional Information

Questions

Sponsor Information

Hold Harmless Agreement

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