Membership Application Form for Association

Membership Application

To apply for membership please complete all questions.
Name

First NameLast Name
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Membership Type
prevnext( X )
1 Year Family Membership
$70.00NZD



1 Year Junior (under 18) Membership
$30.00NZD Quantity



1 Year Mini (under 7yr) Membership
$20.00NZD Quantity



1 Year Senior Membership
$40.00NZD Quantity
Family Membership Names
Rider 1

First NameLast Name
Age and Class
Rider 2

First NameLast Name
Age and Class
Rider 3

First NameLast Name
Age and Class
Rider 4

First NameLast Name
Age and Class
Payment options

Cash at club dayInternet Banking
Please pay to: Bank Name: Dargaville Moto X Club
Bank Acc No: 123098 0286871 00
Should be Empty: