Join Now - Membership Application Form

	* denotes required fields
MEMBERSHIP DETAILS
Type of Membership*
Do you have a proposer or a seconder?*	Yes Please specify Name of proposer* Membership No* Name of seconder* Membership No* No

PERSONAL DETAILS
First Name*
Surname*
Middle Name
Date of Birth*
Marital Status	Spouse name (if applicable)
Street Address*
Suburb*
Postcode*
Postal Address (if different)
Suburb
Postcode
Telephone (home)*
Telephone (mobile)
Facsimile
Email*

EMPLOYMENT DETAILS
Occupation / Profession*
Business Address*
Suburb*
Postcode*
Telephone (work)*
Email (work)*

PROFESSIONAL REFERENCES
Full Name*
Phone*
Email*
Full Name*
Phone*
Email*

OTHER DETAILS
Do you have a criminal offence?* Yes Please provide details No
Have you defaulted on any liability in respect of horse racing or betting, or in connection with ownership of a racehorse?* Yes Please provide details No
Are you, or have you been, a licensed person under the Rules of Racing?* Yes Please provide details No
Do we have permission to give our corporate sponsors access to your address? Yes No

	Privacy - The information collected on this page will be used solely for the purpose of contacting you regarding your membership application.

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