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APPLICATION FOR NEW MEMBERSHIP / CONTINUATION OF MEMBERSHIP
I wish to apply for membership to the Waihi Beach Dirt Track Club and accept that on becoming a member, the Management Committee
and other members shall require me to abide by the Constitution, Rules and Regulations that govern the functions of the club.
Name: _____________________________________________________________________
Address: _____________________________________________________________________
____________________________________________________________________________
Post Code____________________________________________________________________
E-mail: ______________________________________________________________________
Your newsletter will be emailed to you. Should you require a hard copy please advise the Newsletter Editor
Phone: Home _____________________________ Work ______________________________
Mobile: __________________________________ Birthday ___________________________
Please tick membership details: □ New Member □ Renewal
□ Life member: $0 □ Associate Member: $25 □ Full Member: $50 □ Secondary: $25
□ Family $100 (3) □ Family $125 (4)
Direct Credit to: 03 1575 0054960 00 – Your Name as Reference – then post form
Driver Status: □ Driver □ Mechanic □ Lady □ Junior □ Mini Stock □ Adult Mini Stock
Please tick membership details: □ New Member □ Renewal
□ Life member: $0 □ Associate Member: $25 □ Full Member: $50 □ Secondary: $25
□ Family $100 (3) □ Family $125 (4)
Direct Credit to: 03 1575 0054960 00 – Your Name as Reference – then post form
Driver Status: □ Driver □ Mechanic □ Lady □ Junior □ Mini Stock □ Adult Mini Stock
Car Information:
Class: ____________________________ Car Number: ___________ Motor Size: __________
Details of car: _________________________________________________________________
Signature: ___________________________________ Date: __________________________
Postal address:
Class: ____________________________ Car Number: ___________ Motor Size: __________
Details of car: _________________________________________________________________
Signature: ___________________________________ Date: __________________________
Postal address:
WBDTC
P O Box 16,
P O Box 16,
Waihi 3641
