SPORT START PROVIDER REGISTRATION FORM
CLUB/SCHOOL/ORGANISATION NAME
*
SPORT START LIAISON PERSON AT ORGANISATION
*
LIAISON PERSON ROLE/POSITION
*
e.g. Sport Co-ordinator / Accounts / Treasurer
Email Address
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Postal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method of contact
Please Select
Phone
Email
Mail
BANK ACCOUNT DETAILS
ACCOUNT NUMBER
*
Please enter a valid number.
YOUR DEPOSIT SLIP
Please provide a copy of your deposit slip showing the organisation name and account number OR a screenshot showing this information.
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*
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Electronic Signature of liaison person
*
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