Member Request - Porsche Club Canberra

Personal Data

Salutation:

Mr Mrs Ms

First Name:

Last Name:

Username:

Birthday:

. .

2nd Member

First Name:

Last Name:

email:

Contact Data

E-Mail:

Phone:

Mobile Phone:

Address Data

Street Address:

Post Code:

City:

State:

Country:

Porsche #1

Model:

Model Series:

Car Registration

Licence Plate:

Porsche #2

Model:

Licence Plate:

Porsche #3

Model:

Licence Plate:

Date:

23.1.2020

Comment:

Membership Category

Membership Category Level:

Current Financial Club Member (Financial Club Member): 100 A$
Non Current Member (Previous member or current year fees not yet paid): 0 A$
Honorary/Complimentary (** Committee Use Only **): 0 A$

Payment:

PayPal® - Club Preferred Option
Direct Deposit
No Payment Required (Committee Use Only)

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