Little Ripper Gold Inc. Membership Application, Deed of Release, Assumption of Risk & Indemnity Waiver v2

Little Ripper Gold Inc. Membership Application, Deed of Release, Assumption of Risk & Indemnity Waiver
Executed as a Deed. Signed, Sealed and Delivered by the Releasor. By completing and signing this form, I acknowledge that I have read and understand the terms and conditions of Little Ripper Gold Inc. Indemnity Waiver, as outlined on the Little Ripper Gold Inc website.

By completing this Membership Application form (which includes the Indemnity Waiver), you acknowledge that you have read and understood the terms and conditions outlined in the Code of Conduct, Constitution, Indemnity Waiver, Social Media Policy, Advertising Policy and the Aboriginal Heritage Protection Policy, which can all be found on the Little Ripper Gold Inc's website. Annual membership is from 1st January to the 31st December of each year.
Class of Membership*
Select class of membership
Name

First NameLast Name
Preferred First Name/Nickname to appear on your membership card. Your Last Name will be 'as above'.
Preferred First Name/Nickname
Date of Birth

DayMonthYear
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Your Facebook Profile Name*
Business Facebook profiles will not be accepted. If you don't use Facebook, please enter 'Not on Facebook'
Next of Kin

First NameLast Name
Next of Kin's Phone Number

Area CodePhone Number
Have you previously been a member of Little Ripper Gold Inc?*

NoYes
Do you have any association with or are connected in any way to a business that offers gold prospecting goods and/or services?*
Answer Yes or No
If you answered 'Yes' to the above question, please provide details here:
If Yes, please provide details here.
Enter Driver's Licence No. here (if applicable): Driver's Licence No.

Enter Driver's Licence State of Issue here (if applicable): State Licence was Issued
Enter Your WA Miner's Right No. here (if applicable): Miner's Right No.

Enter Your WA Miner's Right Date of Issue here (if applicable): Miner's Right Date of Issue
Upload a copy of your Driver's Licence and Miner's Right here: (if applicable)

File size limited to 5MB each. File types include pdf, jpeg, jpg
Cancelof
Where/How did you hear about Little Ripper Gold Inc?
To become a financial member of Little Ripper Gold Inc (LRG) you will need to do the following:

1. Complete this form and Submit it.

2. Remember to upload a copy of the following documents:

(a) Your current Driver's Licence (if applicable)

(b) Your WA Miners Right (only applicable to Ordinary or Junior Membership)

3. By making an application to become a member or LRG, you enter into a legally binding contract whereby you attest to have read and accept the terms and conditions contained in LRG's Code of Conduct, Constitution, Indemnity Waiver, Social Media Policy, Advertising Policy and the Aboriginal Heritage Protection Policy.

Once you have completed this form and submitted it, your application will be reviewed.

If your application is approved, an invoice will be emailed to you, along with the payment details for the respective membership class.

Once your payment has been processed, a membership card will be emailed to you, along with a permission letter to attend LRG's leases. Only applications that have provided all the information above, will be reviewed.

The committee reserves the right to refuse membership to any person without reason.

Annual memberships run from 1st January to the 31st December of each year.
Signature*

Clear
Parent/Guardian signature if member is under 18yo.
Should be Empty:

Little Ripper Gold Inc. Membership Application, Deed of Release, Assumption of Risk & Indemnity Waiver

Executed as a Deed. Signed, Sealed and Delivered by the Releasor. By completing and signing this form, I acknowledge that I have read and understand the terms and conditions of Little Ripper Gold Inc. Indemnity Waiver, as outlined on the Little Ripper Gold Inc website.