MEMBERSHIP APPLICATION FORM

Feilding Jockey Club

Title

First Name *

Initials

Last Name *

Billing Address *

Billing Postal City *

Billing Postal Code *

Preferred Email *

Home Phone *

Work Phone

Mobile Phone

Date of Birth (for young membership only)

The Rules of Racing require us to ask whether you have been convicted of a Criminal Offence *

Yes
No

If yes, please provide particulars

Please indicate if you were recommended to join by another Club Member as they may become eligible for additional benefits

Referral Member (name)

Terms and Conditions

I accept the Awapuni Racing Centre Terms & Conditions

Declaration

By submitting this form I declare that to the best of my knowledge the details supplied are true and correct. I further declare that I have not withheld any information likely to affect the decision of the Club as to my eligibility for Membership

Subscriptions		Annual
Feilding Jockey Club
	Feilding JC RACE Premier Member	$130.43
	Feilding JC Full Member	$86.96
	Feilding JC Young Member (18-30)	$65.22
Total		$0.00

Note

All prices exclude GST

Payment Method

Credit Card Pay on Invoice

Order Number

Which image is the Motorcycle?

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SECURITY

Online payment transactions are provided through a secure website. However, you acknowledge and agree that internet transmissions are never entirely secure or private, and that any message or information you send to or through our website and while using online transactions (including credit card information) may be read or intercepted by others, even where a website is stated as being secure. RACE Inc and its employees shall have no liability for the interception or 'hacking' of any data through our RACE Inc website or any other website by unauthorised third parties.

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