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Title

First Name*

Surname*

Date of Birth*

Address*

Street Address Postcode

Mobile*

Home Phone*

Email*

Occupation*

Are you Registered with the RNSWBA or WBNSW?

Yes

if yes, state of Rego #

if yes, have you organised a Transfer form?

Are you a member of another Club?

Yes

if so, state Club or Clubs:

Have you ever been suspended, expelled or asked to resign from any club?

Yes

if so, state Club or Clubs:

RNSWBA Number

WBNSW Number

Social Membership*

$11

Total

Do you wish to receive the Annual Report?*

If yes, please choose one:*

Do you wish to receive promotional material including offers relating to promotions and special events which may include gaming materials?*

If yes, please choose one:*

Signature*

Date*

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BECOME A MEMBER