MEMBER DETAILS (Section 1) Please Complete This Clearly and in Full, As Without Proper

MEMBERSHIP APPLICATION & RENEWAL 2016 PO Box 19 Burswood WA 6100

MEMBER DETAILS (Section 1) Please complete this clearly and in full, as without proper contact details the club cannot contact you/send you newsletters/etc…

Name ______

Address ______

Post Code ______Date of Birth ______

Phone ______(h) ______(w) ______(m)

Email Address ______Occupation ______

Licence / Member No. ______Race ID ______R.S.T ______(Your licence no. is your Race ID number, drivers take their Race ID, deckys take their Race ID + B…i.e. driver 001, decky 001B)

MEMBERSHIP AND LICENCE TYPE (Section 2) TYPE OF LICENCE Full $ 100  $______(Tick one only)  Rookie Insurance (per boat number) $ 700  $______Junior (age 14 - 17) $ 100  $______ Novice Rookie (age 10 - 14) $ 50  $______ General Social Member $ 50  $______ 10hp Driver Race ID (Free with full insurance and membership payment before 26/1/16) $ 30  $______

TOTAL $______Date:______NOTE: $700 Insurance per boat payable annually comprises; Public Liability Insurance - $350.00 Personal Accident Insurance - $350.00 PTO CREDIT CARD DETAILS (Section 3) I hereby authorise the Power Dinghy Racing Club Inc to deduct $______from the following credit card;

Card Holder’s Name ______

Credit Card Number ______

Expiry Date ______CVV Number ______(CVV is the 3 digit number on the signature strip on the back of the card)

Card Type (VISA / MasterCard) Issuing Bank ______

Signature as on the card ______- __

INDEMNITY (Section 4) In becoming a financial member of the Power Dinghy Racing Club (Inc) (The Club), I hereby acknowledge that I have read and agree to abide by the rules governing The Club. I absolutely indemnify The Club (Inc) and all and any of its members, employees, officials, officers or helpers of or persons in any way connected with The Club for all actions, claims, costs, demands, damages, expenses, charges, injuries and other losses arising out of or in conjunction with The Club regardless of the nature or cause of any occurrence giving rise to such actions, damages, demands, expenses, charges or other losses. I acknowledge that I am entering and/or participating in The Club entirely and absolutely at my own risk.

Signature ______*By signing this form you acknowledge the indemnity above*

If under the age of eighteen (18) years as at the date of this membership the following is to be completed by a Parent or Guardian.

Name of Parent or Guardian ______

Parent or Guardian Signature ______*By signing this form you acknowledge the indemnity above*

PAYMENT RECEIPTING (Section 4) Admin Payment Method Amount Paid Receipt No. Date Entered Entered By

Only Cash Chq C/C