New Rego Page

Registration Form to Join SCCAVAn

* Indicates required field

Name *

First

Last

Partner's Name *

First

Last

Email *

Phone Number *

Mobile Phone Number *

Fax Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Type of Van *

Model *

Other Type of Van *

Please indicate your preference for the delivery of Newsletters and correspondence: *

Please make your cheque payable to:

Sydney-Central Coast A Van Group Inc. and post with your cheque/money order for $50 to the Treasurer* by 30th June, 2017

OR

Direct Deposits to:
BSB 032 285
Account Number: 485721

(Sydney-Central Coast A Van Group Inc.)Untitled

Please use your name as the Account Name.

Please make your cheque payable to Sydney-Central Coast A Van Group Inc. and print & post this form with your cheque/money order for $50 to the Treasurer* by 30th June, 2017 OR If Direct Deposit is used you MUST still fill in, save, and email a copy to the Treasurer* email: dave.di67@bigpond.com Direct Deposits to BSB 032 285 Account Number: 485721 (Sydney-Central Coast A Van Group Inc.)Untitled *

* The Treasurer, S-CC A VAN Group Inc, Mr. David Luttrell, 8 Benjamin Close,Tumbi Umbi, NSW 2261 I have read and understood the information. Applicant KEY IN NAME or SIGN ## KEY IN or PRINT IN BOX ## Signed Date Spouse/Partner KEY IN NAME or SIGN ## KEY IN or PRINT IN BOX ## Signed Date ## BY E-MAILING THIS APPLICATION YOU ACKNOWLEDGE THAT A SIGNATURE HAS NOT BEEN GIVEN AND THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT IN ALL RESPECTS The Sydney-Central Coast A'Van Group Inc. does not accept any liability that may occur involving a member enroute to, from, or during, any gathering or Club function. Participants choose to take part in any Club Activities at their own risk. *

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