Membership Application for the Wellington Racing Club

Membership Application for the Wellington Racing Club
Date (dd/month/yyyy)
I wish to join the Wellington Racing Club Incorporated as a :
Membership type
Date of birth (only required for "Young Membership" dd/month/yyyy)
Note that the racing season runs from 1 August to 31 July
Title (Mr/Mrs/Ms/Miss/Other (Please specify))
Preferred First Name
Initials
Surname
Postal Address (including post code)
Home Phone
Mobile
Work Phone
Email
Employer
Occupation
The Rules of Racing require us to ask whether you have been convicted of a Criminal Offence

If YES Please supply particulars
As a member of the Wellington Racing Club, you will be provided with a copy of the clubs annual report.
Please indicate if you were recommended to join by another Wellington Racing Club Member as they may become eligible for additional benefits
Payment
Credit Card Number (Visa or Mastercard only)
Credit Card expiry date (MM/YY)
Name on Credit Card
Please note that you may phone the WRC on 04 528 9611 to provide your credit card details verbally or to arrange other payment methods
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 Wellington Racing Club Inc as to my eligibility for Membership
Comments (if applicable)
CAPTCHA
captcha
Please enter the letters/numbers above exactly as you see them. Uppercase and Lowercase are important.