Membership Application Form

www.ctccwa.com ctccwa@gmail.com

PO Box 304, Bentley WA 6982

Ph: 0409 497 772
New Membership Application Form
** DEPARTMENT OF TRANSPORT REQUIREMENT **
** IMPORTANT**

A seperate membership is required for EACH & EVERY person that has a vehicle registered in their name on either concessional system CODE404 or C4C - e.g. a husband and wife have a vehicle under each of their names on either CODE404 or C4C you each need a membership in your own name i.e. the name your vehicle is registered in. This is a DOT requirement and NOT negotiable. THIS FORM IS FOR ONE MEMBERSHIP ONLY, PLEASE COMPLETE A NEW FORM FOR EACH MEMBERSHIP REQUIRED.
Personal Details
Name*

First NameLast Name
Nick Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Please enter a valid mobile number.
Home Number
Please enter a valid landline number.
Email*
example@example.com
Emergency Contact Name
Emergency Contact Mobile Number
Please enter a valid mobile number.
Emergency Contact Home Number
Please enter a valid landline number.
Personal Details (Optional)
Date of Birth

DayMonthYear
Optional
Marital Status
Optional
Occupation / Interests
Optional
Vehicle Profile
Model/Year
Style (SL, GR, Sunbird etc)
Colour
2/4 Door
Engine
Transmission
Other
Membership Cost Per Annum inc GST*

Individual Membership $50
Payment Details

Please deposit payment upon submission of this application to

CTCCWA BSB: 036 032 Account No.: 466758 with “Your Name – Join” as the reference.
Acceptance of Conditions: With submission of this application I agree to abide by the constitution of the Combined Torana Car Club of WA (inc) and by the Law, and behave according to standards set by the Club and its members.*

Agreed to Acceptance of Conditions
Payment Instructions*

Please deposit payment upon submission of this application to: CTCCWA BSB: 036 032 Account No.: 466758 with “Your Name – Join” as the reference.
Submission Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

New Membership Application Form

** DEPARTMENT OF TRANSPORT REQUIREMENT **

** IMPORTANT**

Personal Details

Personal Details (Optional)

Vehicle Profile

DEPARTMENT OF TRANSPORT REQUIREMENT

IMPORTANT