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Membership Application

New Membership 2009/10

Personal Details

Title:
First Name:
Last Name:
Postal Address:
City/Suburb:
State:
Postcode:
Occupation:
Company:
Home Phone:
Business Phone:
Fax:
Mobile:
Email:
Date of Birth:
Marital Status:

Membership Details


Membership Type:
Nomination Fee (Cost: $25.00)
Note: Nomination Fee required for new members
Full Membership (Cost: $120.00)
Senior Membership (Cost: $80.00)
Colts & Fillies Membership (Cost: $60.00)
Single Membership (Cost: $60.00)

Payment Details

Cardholder's Name:
Credit Card Type:
Credit Card Number:
Expiry Date: /

Terms and Conditions

As a member of the Geelong Racing Club I am agreeing to adhere to the rules and regulations of Country Racing Victoria. I will adhere to the No BYO policy of the Club and will conduct myself in a modest manner. Any infringement could result in the termination of your membership.

I agree to these terms and conditions

Please type the following security code: