CONFRERIE DE LA CHAINE DES ROTISSEURS

                     Bailliage de Greater Fort Lauderdale
        10381 Golden Eagle Court, Plantation, Florida  33324
    Phone: (954) 954-452-8328           Fax: (954) 954-916-3643
                             e-mail: heidiro@bellsouth.net

                                    Application For Reinstatement
                                    (Please type or print clearly. One application per person)
Date: ___________________________ Bailliage___________________________________
        􀂈 Miss 􀂈Ms. 􀂈Mrs. 􀂈Dr. 􀂈Mr.
Name _________________________________________________________________________________________________________________________________________
                Last                                         First                                                             Middle
Check one box where mail should be sent:
􀂈 Home  
 Address_____________________________________________________
 City__________________________________State___________________                                                                       Zip__________________________                         Country______________________________Phone___________________                                                               Fax________________E-Mail: ___________________________________ _____________________________________________________________________________________________________________________________
􀂈 Name of Firm ____________________________________________________Position______________________________________
Type or Nature of Business ____________________________________________________________________________
Address _______________________________________________________________________
City__________________________________ State_____________________ Zip _________________________
Country _____________________________
Phone ___________________________ Fax _______________________________ E-Mail: _________________________________________________________
Website: ________________________________________________________________________________________________________________________________
Date of Birth ________________________Place of Birth ________________________________________ Citizen Of_________________________________________
Full Name of Spouse ______________________________________________
Is Spouse a Member? ____________________________________________________
When did you join the Chaîne? ___________________________________
When was your last active year? _______________________________________
Chaîne Grade ______________________________________________________
Date Inducted ___________________________________________________________
What Chapter? ____________________________________________________
 Do you have a wine cellar? _____________________________________________
Approved by Chapter Bailli ____________________________________________________________________________________
Your check must accompany this Application:
                                                                        National and International Dues $ ______________________
                                                                                            Reinstatement Fee $ ______________________
                                                  Note: If Replacement Ribbon is required, Add $ ______________________
                   TOTAL FEES PAYABLE TO “CHAÎNE DES RÔTISSEURS” $ _______________________