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Personal Data

Title:

Mr. Mrs. Ms. Dr.

First Name:

Last Name:

Contact Number:

E-mail:

Partner Salutation:

Mr. Mrs. Ms. Dr.

Partner First Name:

Partner Last Name:

Partner E-mail:

Child Name:

DOB (dd/mm/yyyy):

Child Name:

DOB (dd/mm/yyyy):

Child Name:

DOB (dd/mm/yyyy):

Contact Data

Address:

City:

State:

Postcode:

Country:

Contact Work:

Contact Home:

Contact Mobile (Used for SMS Alerts - Use the Format 04XXXXXXXX - No Spaces or Other Characters):

Partner Mobile:

Business Details (you may include your business details in club publications):

Include Business Details

Business Category (ie. Real Estate, IT):

Business Locality:

Business Name:

Business Contact Ph:

Business Web Site:

Business Contact Name:

Porsche Details

1. Model (ie. 911):

Type:

Year:

Registration:

Colour:

2. Model:

Type:

Year:

Registration:

Colour:

3. Model:

Type:

Year:

Registration:

Colour:

4. Model:

Type:

Year:

Registration:

Colour:

5. Model:

Type:

Year:

Registration:

Colour:

Membership fee

New Club Member:

No Yes

Membership fee level:

Level 1 (You are an independent full member): 120 A$
Level 2 (You and your partner and children under 17 are full members): 150 A$
Level 3 (You are an under 17 full member): 60 A$

Level 1 (You are an independent full member): 180 A$
Level 2 (You and your partner and children under 17 are full members): 210 A$
Level 3 (You are an under 17 full member): 120 A$

Payment:

Pay by Cheque or Direct Deposit
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