Honolulu Lodge 616 BPOE

Membership Dues
Secure Payment Form



Member Dues Statement Summary:
Transaction Date:	12/21/24
	Insert Quantity in the Boxes Below & not "$" amount. ONE FORM PER MEMBER

Regular Dues +GLSA - $400.00:
Life Dues +GLSA - $65.00:
Elks Lodge National Foundation-Optional - $25:
Major Project Purple Pig-Optional- $25:
Scholarship for Hawaii students-Optional $25:
First Parking Decal - $100:
Second Parking Decal - $150:
Men's Locker Room Entry Key Card - $90:
Women's Locker Room Entry Key Card - $90:
Pre-Assigned 3ft Locker With Lock - $90:
Pre-Assigned 2ft Locker With Lock - $70:
Men's Fitness Room Entry Key Card - $150:
Women's Fitness Room Entry Key Card - $150:
Pre Assigned Surf Board Rack - Regular Size - $180:
Pre Assigned Surf Board Rack - Large Size - $240:
Pre Assigned Canoe Rack - $300:
Initiation Fee - $1900:
Total Charge $:

Credit Card Information:
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Card Billing Zipcode:
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Card Expiration Date:	MMYY
Card ID (CVV2/CID) Number: [What is the Card ID?]

Member Information:
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Honolulu Lodge 616 BPOE - 2933 Kalakaua Ave Honolulu, HI 96815 For questions or concerns, please call: 808.923.5722 www.elkslodge616.org