2015 Membership Application .pdf

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