Today’s Date:


___ Pay in Full ($450)

___ Monthly Payments ($37.50)

Last Name:                                                    First Name:

Street Address 1:                                                      Street Address2:        

City:                                                                            St:                               Zip:

Primary Phone:                                                         Secondary Phone:

Emergency Contact:                                                Phone#:

Email Address:

Occupation:                                                   Employer (Optional):

Hobbies:                                                                    Shirt Size:


Cigar Preference #1

Cigar Preference #2

Cigar Preference #3


Drink Preference #1:

Drink Preference #2:

Drink Preference #3:

To complete the application process, please review the following information, complete and return the application form to The Loft Cigar Lounge via email ( or in person. Upon receipt of your application you will receive a link via email or text message requesting your credit card information.

It is The Loft Cigar Lounge’s (The Loft) obligation to enforce these rules and regulations.  It is the duty of members to know The Loft’s rules and regulations and to cooperate with the staff in the enforcement thereof.  Failure to comply with the terms and conditions of membership may lead to termination of membership (without refund) at the sole discretion of The Loft. By entering this agreement, the parties agree to the following terms:

  • Payment for membership is due upon signing and is non-transferable and non-refundable.
  • Membership is on an annual basis. Your membership is effective on the date you sign and pay for your contract.
  • The Loft reserves the right to refuse service, as well as access to the business to any person.
  • Membership charges or fees are automatically processed on the date in which you signed, each month throughout the term of this contract.
  • The Loft reserves the right to amend this contract at any time.
  • Membership may be suspended or revoked for non-payment of a bill, breach of this contract, misconduct, unpaid fees or failure to adhere to any of the rules, regulations, and policies set forth by The Loft.
  • Members are to comply with all local, state and federal laws. It is The Loft’s policy that no illegal substances nor materials, including but not limited to, any firearms or weapons will be placed or stored in any of the cigar lockers. The purposes of the lockers are to hold and store legal tobacco products and accessories (i.e. lighters, cigar cutters, ashtrays) that are incidental to cigars.
  • The Loft bears no responsibility for any of the contents stored within the cigar lockers.
  • The Loft maintains access to all lockers, and reserves the right to access the lockers at any time necessary by The Loft’s policies and by law.
  • Upon termination of membership, all locker contents must be removed within 24 hours or items shall be deemed abandoned and will be disposed of in any manner Management may elect.
  • Locker replacement key fee is $50.

I understand that to guarantee my membership stays continuous with no interruptions or change of benefits, a valid credit card must be placed on file with The Loft Cigar Lounge (The Loft). I have received a copy of the membership application and agree to adhere to and abide by The Loft’s membership rules and regulations as amended from time to time.  I hereby acknowledge that all fees will be billed on a monthly basis.  The Loft reserves the right to cancel all membership privileges, and re-allocate my member locker upon one week (7 days) of my monthly payment being past due. I further certify that the credit card submitted is issued to me and agree that all disputes on the credit card account relating to The Loft will be brought to The Loft’s attention within 30 days of any transaction.  I hereby agree to keep a valid and approved credit card on file with The Loft at all times.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify The Loft in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.

I have read and agree to comply with the rules and regulations set forth in this contract and membership application.  I pledge that all information provided is accurate and truthful.  Any fraudulent information provided can result in immediate termination of my membership without refund.

Client Signature: _____________________________________________________