Central Coast Four Wheel Drive Club Incorporated

(Incorporated under the Associations Incorporation Act 1984.)

MEMBERSHIP RENEWAL

FEE STRUCTURE: Fees are payable with application and cover a financial year.

ANNUAL MEMBERSHIP = $80.00, GOLD = $40.00, LIFE = $25.00 (DUE 1ST JULY)

NOTE: For membership purposes your one fee covers individuals and families.

Families may consist of any number of children under the age of 17 years.

RENEWAL DETAILS

(Please Print All Details)

Date: _11th July 2012

(Please List All Family Members, including you, that will be included in the membership)

Surname / First Name / Signature / Birth Date
(under 17)
Wells / Tony / Tony Wells
Wells / Janice / Janice Wells
Membership Number / 1068
Address (Street & No) / 102 Springwood St
Address (Suburb ) / Ettalong Beach / Post Code / 2257
Home Phone / 02 4341 4885
E-mail /

DECLARATION: By the placing of my/our signature(s) above I/we hereby apply to renew my/our membership of the above named club and in the event of my/our renewal as a member(s) I/we agree to be bound by the rules and the by-laws of the club as currently in force.

4WD VEHICLE

Make / Toyota / Model / Landcruiser 80s
Type (eg Wagon) / Wagon / Type No. (eg HJ60) / 1HZ GXL
Year of Manufacture / 1993 / Petrol or Diesel / Diesel
Rego Number / TW1959 / CB Call Sign

INSURANCE: We confirm that our vehicle is covered by at least 3rd party insurance

OTHER DETAILS

MAGAZINE:

We would like to receive a priority full colour E-version of the Club Magazine, to the e-mail address provided instead of a hard copy printed version.

E-mail /

A printed version (hardcopy) can be supplied if requested; tick here. Please consider E-Version as your preferred choice.Not required

PRIVACY

For convenience of club members who may wish to contact other members regarding trips, meetings & events etc and for identification whilst in convoy, members details such as names, addresses, phone numbers and vehicle details are periodically published in the club magazine & literature

Do you object to having our details published in club literature?

Yes No (Please tick)

Signature ___Janice Wells & Tony Wells______Date: ___11th July 2012______

Receipt Number if paid by Electronic Transfer: ______

MANAGING COMMITTEE USE ONLY
Membership Year / Date Paid
Amount Paid / Receipt Number
Membership Number

CC4WD Membership Renewal Page 2