PBC Registration

PBC Registration $104.00

Application must be received by April 16th, 2025.

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.

Applicant Information

First Name

Middle Name (optional)

Last Name

Address

City

State

ZIP Code

Phone (Work)

Phone (Home)

Name of Wife or Next-of-Kin

Additional Information

Place of Birth

Date of Birth

Employer Name and Address

Questions

Do you believe in our Supreme Patron, Saint Vitus?

Would you give a sucker an even break?

Will you respect authority under the silk hat?

Will you temper the Sword of Justice with Mercy?

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

Reason for joining Clampers?

Contribution by you or your ancestors to California History?

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

Sponsor Information

Sponsor Name

Sponsor Phone Number

Date of Membership

Agreement

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