APPLICATION FOR MEMBERSHIP 2017– General (Non Bowling Club)

We hereby make application for membership of the Licensed Clubs Association of South Australia and supply the following information;

Full Club Name
Street Address
Post Code
Postal Address
Post Code: / Post Code
Telephone
Email
2nd Email
3rd Email
After Hours Phone
Name of Manager/Secretary
Delegate Name (1)
Delegate Name (2)
Person to Receive Correspondence

Licence

What type of Licence does your Club hold?

 Limited Club LicenceClub LicenceOther ______

Staff

Number of Full Time Staff / Number of Casual Staff
Number of Part Time Staff / Number of Volunteer Staff

Member Numbers

Full / facebook page / Yes / No (Please circle)
Social / twitter Account / Yes / No
Junior / instagram / Yes / No
Total / Webpage address / Yes / No

Parent Body:Affiliated Clubs:

(eg State Association)(attach separate list if required)

Application continues over the page

CLUBS SA

Please return this form to Clubs SA via email or post:

A: Clubs SA House 222a Henley Beach Rd Torrensville SA 5031

E: T: (08) 8290 2200

What are your peak season opening hours?

MONTHS / FROM / TO
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Gaming

Does your Club have Electronic Gaming Machines? / Yes / No
If yes, how many?
Does your Club have TAB? / Yes / No
Does your Club have Keno? / Yes / No

Fees

  • Please note membership fees are paid for one calendar year – pro rata fees can be arranged for remainder of one year followed by a full 12 months for the following year. Please call the Clubs SA office for details.
  • All fees are inclusive of GST (10%)
  • Please circle the relevant level of membership listed below;

Type of Membership

Limited Club Licence / $ 424.00
Club Licence (Volunteers Only) / $ 848.00
Club Licence (Paid Employees) / $ 1,272.00
Gaming Licence;(Base) + (a) or (b) / $ 1,272.00
(a)Per Machine (1-10 Machines) / # Machines x $32.00+ $1,272.00 =
(b)Per Machine (11-40 Machines) / # Machines x $47.00 + $1,272.00 =
Special Circumstances Licence / Contact Clubs SA for Pricing

Period of Membership: Start Month ______to December 2017

Note: Direct Debit facility is strongly encouraged.

Please find enclosed a cheque for $ ______or by EFT to BSB 085 375 Account 248 605 353 OR

Direct Debit form attached.

I declare that the above is a true and correct record.

NAME:

SIGNATURE:DATE:

CLUBS SA

Please return this form to Clubs SA via email or post:

Postal: Clubs SA House, 222a Henley Beach Rd, Torrensville, SA, 5031

Email: Phone: (08) 8290 2200Fax: (08) 8290 2222