Gold Card Request Form

Please select one:	New Member Replacement Update
Your Name:* (First, Middle Initial, Last)
Address:*
Address Line 2:
City*, State*, Zip*:	PA AK AL AR AZ CA CO CT D.C. DE FL GA HI IA ID IL IN KY KS LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PR RI SC SD TN TX UT VA VT WA WI WV WY
Phone*
Driver License #:*
Email:*

PRIVACY POLICY: At Shurfine Markets, we seriously regard the privacy of our customers and pledge to serve your shopping needs. An important part of this pledge is our desire to gain and maintain your trust and confidence. You can rest assured that all personally-identiying information gathered through the Shurfiine Gold Card program will be treated with the highest level of confidentiality. At no time will your name, address, or personally-identifying information be leased, sold or shared in any way with a third party. "Personally-identifying information" means your name, address, telephone number or other information by which you can be personally identified. Shurfine may disclose personally-identifying information as required by law.