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Membership Application Form
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* Indicates required question
Email
*
Your email
Name (full name)
*
Your answer
Residential Address Town/Sate/PC
*
Your answer
Postal Address Town/State/PC
*
Your answer
Phone number
*
Your answer
Payment Options:
(tick only one)
Please use “Full name” as payment Reference and
email Direct Deposit Advice with application
*
Direct Deposit. Acct Name: Wide Bay Motor Complex Inc, BSB: 124-080, Acct Number: 215-030-56
Cash
Membership Options
*
General Membership ($40.00 P/YR)
Junior (under 17) Membership ($25.00 P/YR)
Do you agree to the terms and conditions of Membership?
(terms and conditions on website)
*
Yes
No
Date
*
MM
/
DD
/
YYYY
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