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Bench Club Application Form
Fill out the form below for Bench Club membership

Required Fields in Bold
First Name:
 
Last Name:
 
E-mail:
 
Phone:
 
Fax:
 
Address Line 1:
 
Address Line 2:
 
City:
 
State:
 
Zip:
 
Pledge Amount
 
Green and Silver: ($25-$99)
Zia/Greyhound: ($100-$249)
Silver Hound: ($250-$499)
Silver Zia:($500-$999)
Team Captain: ($1,000-$1,749)
Head Coach: ($1,750-$2,499)
Gold Zia/Hound: ($2,500-$4,999)
Platinum Partner: ($5,000 plus)
 
Please note exact pledge amount in U.S. dollars:
 
Please mail checks to: Athletics Bench Club ENMU Station 17 Portales, NM 88130
Payment Options:
 
I'm mailing a check to the address above
I'm using a credit card, please call me for my credit card information
Bill me for one lump sum
Bill me monthly
Bill me quarterly
Bill me semi-annually
Bench Club Benefits If you choose to receive benefits, you cannot claim the above amount pledged on your personal/business income tax return as a tax deduction. If you do not plan on claiming the tax deduction, check the "Yes" box below.
Would you like to receive benefits?
 
Yes
No
Additional Comments:
 
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