Club 500 Registration Form

Entry Type: *

Name *

First Name Last Name

Syndicate Name *

Date of Birth *

Date

Syndicate Contacts Date of Birth *

Date

Email *

Syndicate Contacts Email *

example@example.com

Phone Number *

Area Code Phone Number

Syndicate Contacts Phone Number *

Area Code Phone Number

Do you wish to keep your original Club 500 number?

What is your original Club 500 Number?

How would you like to pay? *

Pay Online: *

2021 Club 500 - Fortnightly Direct Debit

$ 40.00 AUD for each two weeks

2021 Club 500 - Full Payment

$ 1,040.00 AUD for each year

Email

Credit Card Details:
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Pay Via Bank Transfer:

Participants also have the option to pay the full amount ($1,040) in a one-off payment. If this is your preferred option, please deposit $1,040 into the following account:

Account Name: NBFC Club 500 Account

Bank: Bendigo Bank

BSB: 633 000

Account Number: 182 008 979

Reference: 'your name' Club 500 - Example 'John Smith Club 500'

*Your card will not be charged until the mininum number of participants has been reached and draw start date has been set. Your spot in the Club 500 draw is not secured until payment has been received

The Club will contact you shortly with an email confirmation of your ‘lucky’ number and your Club 500 pack.

Good luck and thank you for supporting the North Ballarat Football & Netball Club.

By pressing submit you acknowledge that you have read the T+C's and are entering the North Ballarat Football & Netball Club 500 and the Club will use your information to contact you if successful

Please verify that you are human *