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Gold Star Executive Member Pre-registration Form

Primary Card

*  …Required.
**…Minimum One telephone number required.
Nearest Warehouse*
Primary Member Name*
First Name

Last Name
Address*
Zip Code
－
Prefecture (Auto Input)

City/Town/Ward (Auto Input)

Address 1

Address 2

Home Phone Number**
- -
Mobile Phone Number**
- -
Email Address*
Re-enter Email Address*
Date of Birth*
Year:Month:Day:
Sex*
ID*
ID Type (including current address)

Other：
  • ・Permit of Boat’s Operator, Physical Disability Certificate, Mental Disability Certificate (with photo)
    • Or, two of the followings:
  • ・Passport (with no information on bearer and address information)
  • ・Insurance card, National Health Insurance card, or other insurance card such as Seamen’s Insurance (with no address)
  • ・Mutual Aid Associations card
  • ・National Pension card
  • ・National Pension, Employees’ Pension Insurance, or Seamen’s Insurance certificate
  • ・Mutual Aid Association pension certificate
  • ・Student ID, Employee ID, or ID issued by public organization with photo
  • ・Utility bills

Household Card　(Optional) *Spouse / Domestic Partner

A free Household card is available to a Primary cardholder’s spouse, domestic partner, or immediate family member over the age of 18 and living at the same residential address. Household cardholders will be asked to present proof that they live at the same address as the Primary cardholder.

Request Free Household Card


Please check the following item for confirmation.

I did not cancel Costco membership within last 12 months.

I was a Costco member before.

Submission of this application by clicking the "Accept" button shown below constitutes acceptance of Costco's Member Privileges and Conditions, Executive Reward Terms and Conditions, and Privacy Statement.