2015 Membership Application .pdf

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Original filename: 2015 Membership Application.pdf
Author: Craig Leven

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2015
APPLICATION FOR MEMBERSHIP OF ASSOCIATION
Dubbo City Car Club Incorporated
ABN 63 603 148 610
PO Box 1054 Dubbo NSW 2830
Ph 0427 843 588
Email: dubbocarclub@live.com.au

(incorporated under the Associations Incorporation Act 1984)

Name:________________________________________________________________________________
Address:______________________________________________________________________________
Phone:____________________

Mobile:___________________

Fax:_____________________

E-mail:________________________________________________________________________________
DOB:____/____/________

Occupation:______________________________________________

What Vehicles do you own?:_______________________________________________________________
______________________________________________________________________________________
If family membership, please list Names and Ages:
1:____________________________________
2:____________________________________
3:____________________________________
4:____________________________________
5:____________________________________

Age________
Age________
Age________
Age________
Age________

I hereby apply to become a member of the Dubbo City Car Club Inc. In the event of my admission as a
member, I agree to be bound by the rules of the association for the time being in force.
_________________________
Signature of applicant

____/____/________
Date

Annual Membership Rates (Please include Fee with application)
Single
$10.00
Additional Family Members (13 & Over)
$5.00
Additional Family Members (12 & Under)
$1.00

$________
$________
$________

TOTAL:

$________

MEMBERSHIP RECIEVED:____/____/________
Payment:

Send Chq or Money order to DCCC, P.O. Box 1054, DUBBO NSW 2830
Cash - Drop in to see Brett or Craig at Autobarn Dubbo
Direct Deposit - BSB: 932 000 Acc. No: 35407 - Use Surname as a reference


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