Membership Registration Step 1 of 2 50% Type of Membership*JuniorSeniorFamilySocial non competitiveSingle or Couple?*SingleCoupleName* First Last Person 1* First Last Person 2* First Last Junior First NameJunior Last NameSenior - First NameSenior - Last NameFirst NameLast NameAdd 2nd Adult Yes No 2nd Adult - First Name2nd Adult - Last NameAdd Child Yes No Child #1 First NameChild #1 Last NameAdd 2nd Child Yes No Child #2 First NameChild #2 Last NameAdd 3rd Child Yes No Child #3 First NameChild #3 Last NameAdd 4th Child Yes No Child #4 First NameChild #4 Last Name Email* Mobile*Postal Address* Street Address Address Line 2 Suburb State Post Code Credit Card* MasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Security Code Cardholder Name Junior Membership Price: $ 60.00 Senior Membership Price: $ 80.00 Family Membership Price: $ 100.00 Social memberships Price: $ 40.00 Signature*I hereby agree to abide by the North West MCC Supplementary Regulations and the rules governing the Motorcycling Australia Rule Book. Please note: Membership is due on the 1st of each new year and expires on the 31st of December of the same year. Membership must be paid before any competitor can race. IMPORTANT NOTE: Completing this membership form and making payment does not automatically entitle you to membership of this club. The committee has the right to reject your application without reason.EmailThis field is for validation purposes and should be left unchanged.