Queensland Lure Coursing Association Incorporated / MembershipNumber
IA05669 / - - - - - / ------
ABN 23 309 683
MEMBERSHIP APPLICATION
NEW / RENEWAL
Receipt Number
(Circle which applies)
Send to: / Method of Payment:
Membership Officer / Direct Deposit—account details over
QLCAI / Cheques—Made payable to QLCAI
PO Box 366 / Money Order—Made payable to QLCAI
Underwood Qld 4119 / Cash—No cash through post

PLEASE NOTE FAMILY MEMBERSHIPS ARE ONLY APPLICABLE FOR THE SAME RESIDENTIAL ADDRESS

PLEASE PRINT IN CAPITAL LETTERS

First Name: ……………………………………………. Last Name ……………………………………………..

First Name: ……………………………………………. Last Name: ……………………………………………..

Address: …………………………………………………………………………………………………………………

………………………………………………………………………………………………………………...

Telephone: Home ( ) ………………………………...….Work ( ) …………………………………….……...

Mobile/s: ……………………………………………………………………………….………..

Email: ……………………………………………………………………………………………………………………

I / We hereby provide permission for QLCA Inc to enter my / our email address into the

Association’s Email message newsgroup to communicate with members and receive updates and club in-formation.

YesNo

Competitor Information

Breed / Call Name / DOB / CCCQ Reg No
(for Pedigree Dogs)

Please note: Any member found guilty of baiting a dog with live game shall immediately be banned for life from membership of the Association, subject to Clause 8b (vi) of the Constitution.

(continued over …………..………………….2/)

Declaration:

I confirm that the dog/s I will bring to Queensland Lure Coursing Association meetings arenot of the following breeding (or crosses thereof) - American Pit Bull Terriers ,Japanese Tosas,Argentine fighting dogs,Brazilian fighting dogs.

I further confirm that my dog/s are notdesignated asregulated dogs, whichis— (a) a declared dangerous dog; or (b) a declared menacing dog; or (c) a restricted dog asdefined by any State / Territory Act within the Commonwealth of Australia.

If required byQueensland Lure Coursing Association I will provide documentationthat will confirm these requirements.These documents could include but are not limited to registration with ANKC, council dog registration or registrationwith an approved canine organisation.

Iagree to be bound by the Rules, Regulations and By-Laws in accordance with the Constitution and as otherwise set out by this Association.

Signature: ………………………………………………..……………….. Date: …………………………………..

Signature: ………………………………………………..…………………. Date: …………………………..………

ALL MEMBERSHIP FEES ARE DUE 31 JANUARY OF EACH YEAR

(Please circle selected fees)

ANNUAL MEMBERSHIP FEES:

Email Pursuit Single: / $20.00 / OR / Family $30.00
Paper Pursuit Single: / $25.00 / OR / Family $35.00

Direct Debit payments to :

Bank of Queensland

Queensland Lure Coursing Association

BSB 124030

Account 90193946

NOTE : if paying by direct debit you must include your payment receipt along with a completed Membership Application Form and POSTboth to - Membership Officer QLCA, P O Box 366, Underwood 4119 so your membership can be accepted.

FOR NEW MEMBERS ONLY

PROPOSED BY: NAME: ……………………………………………... SIGNATURE: …………………………………………

SECONDED BY: NAME: ……………………………………………... SIGNATURE: ………………………………………….

OFFICE USE ONLY:

DATE RECEIVED: ……………………………..

RECEIPT NO: ………………………………………

RENEWAL DATE:

30/01/20……..