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Membership 2015 Application Form MEMBERSHIP 2015 APPLICATION FORM 1. MEMBER DETAILS Mr / Mrs / Ms / Miss / Dr (Please circle) DOB: / / MyRugby ID: Member Since: Given Name: Surname: Company Name: Address: Suburb: State: Postcode: Email: Mobile: Other Contact No: School or Rugby Club: 2014 Membership Type: 2. RENEW YOUR SEATS 4. PAYMENT PLAN All existing Members have the right to renew their same 2014 seats. Using your credit card or debit card, you can pay for your membership Your current allocation is guaranteed provided the Melbourne Rebels over 10 monthly installments. By selecting the Monthly Payment Plan receive your payment by Monday 20 October, 2014. you will also be included into an Auto Renewal Agreement, whereby Please select ONE OPTION only your membership will be automatically rolled over for 2016 season, saving you the hassle of filling in forms or remembering to renew. Please renew my seats without any changes I request a seat upgrade should one be available For more information or to view the terms and conditions please visit melbournerebels.com.au/membership 3. MEMBERSHIP PACKAGES *A one-off $5 administration fee applies per order and will be deducted as part of your first installment. I authorise the Melbourne Rebels to deduct 10 installments from my credit card, with the first PACKAGE TYPE 8 Game QTY TOTAL installment being deducted on receipt of this application and the other nine installments being deducted as per the payment schedule outlined in the terms and conditions. I have read and Weary accept the terms and conditions of the Monthly Payment Plan. Dunlop Adult $1,920 $ Rugby Club 5. PAYMENT DETAILS Adult $476 $ TOTAL AMOUNT PAYABLE: $ Conc. $420 $ Platinum Credit Card Cheque (Payable to: Melbourne Rebels Rugby Union Ltd) Junior* $210 $ Credit Card Type: Mastercard / Visa / Amex (Please circle) Family** $1,155 $ (2% surcharge VISA and Mastercard, 3% on AMEX) Adult $371 $ Credit Card Number: Conc. $301 $ Gold Junior* $140 $ CCV: Expiry: Family** $ $875 (Three or four digit security number located Adult $250 $ on the back of your card) Silver Stars Conc. $170 $ Cardholder’s name: Family** $410 $ Adult $150 $ Signature: Date: / / Blue Conc. $120 $ Rebel ACCEPTANCE & CONSENT Army Blue Junior* $60 $ I have read and understood the terms and conditions. Full terms and conditions can be Family** $360 $ found at melbournerebels.com.au. I do not wish to receive emails from RaboDirect Rebels, Melbourne Rising, ARU, NON-MATCH DAY PACKAGES Super Rugby, or related rugby organisations. Adult $50 $ I do not wish to receive SMS messages from RaboDirect Rebels, Melbourne Rising, ARU, Super Rugby, or related rugby organisations. Conc. $30 $ I do not wish to receive special offers from RaboDirect Rebels, Melbourne Rising, Supporter ARU, Super Rugby, related rugby organisations sponsors or third parties. Junior* $25 $ International^ $70 $ Signature: With Adult $50 $ Non-Member Little Rebels With Adult Member $25 $ SUBMIT YOUR FORM Baby Rebels — $30 $ PHONE: Call our friendly Membership Team on 1300 GO REBELS (1300 46 732357) and we’ll Exclusive S M L $40 $ help you select your preferred Membership. Member Polo XL XXL Remember to let us know if you want an upgrade with your Membership. SUBTOTAL $ MAIL: Complete an application form and return it to: TOTAL $ Melbourne Rebels Membership *Junior Member: 16 years or under at Oct 1, 2014. **Family: 2 Adults + 2 Juniors OR 1 Adult + 3 Juniors PO Box 29, Parkville, VIC 3052 ^International supporter package includes overseas postage For further information and enquiries, contact the Club at: melbournerebels.com.au 1300 GO REBELS (1300 46 732357) REB507.
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