Blanchetown Dirt Kart Club Single Membership Application
Please note you must be a financial member of a club before you renew your Dirt Karting of Australia license. At the conclusion of your Membership Application form, you will receive our Bank Details in the 'next steps' section. Please use these Bank Details to make a prompt payment towards your application.
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Membership Details
Please complete the following information so that we can process your membership application.
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this the same as your postal address?
Yes
No
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Mobile)
*
Please enter a valid phone number.
Format: 0000-000-000.
Phone Number (landline)
Please enter a valid phone number.
Format: 0000-000-000.
Email
example@example.com
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Single Membership Licence Details
Please fill out the applicable details for a Single Membership
Dirt Karting of Australia Licence Type
Please Select
Senior
Junior
Pit Crew
Official
New Member
Dirt Karting of Australia Licence Number
Please enter your kart details:
Rows
Kart Number (eg. 56)
Class Normally Raced (eg. 125 Medium)
Kart Number 1
Kart Number 2
Kart Number 3
Kart Number 4
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Ambulance Cover
You are required to have Ambulance Cover as part of your Licence Conditions. Please upload a current copy of your ambulance cover. Please note - your membership will not be processed without this.
Ambulance Cover Organisation Name
Ambulance Cover Membership Number
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Next Steps
Please make payment via direct deposit to: BSB 065-520 and Account Number 10011139 using your Last Name as the reference. Once payment has been made, please retain your payment confirmation for your records. Processing will commence once the payment has been received and reconciled.
Consent and Terms and Conditions
Please read the following links to ensure you are familiar with the clubs Terms and Conditions and Code of Conduct. Please note that you ticking is your understanding of all that is expected of you. Your submission binds you to complying with these Terms and Conditions and Codes of Conduct and if you are found in contravention of them, your membership may be suspended or cancelled.
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