Members Details:

Name: Associates Name/s:

Address:

Suburb/Town: State: Post Code:

Postal Address (If Different):

Home Phone #: Work Ph #: Mobile #:

Email:

Are you happy for your details to be shared with other club members? Yes No

Vehicle Details:

Year: Make: Model: Marque:

Registration #: Colour: Engine Size:

Engine #: Body #:

Chassie #:

CAMS log book?: Yes No

Fees:
• Annual Membership - $60.00 per family (residing at the same address). (MAY is membership due date, if applicable membership will be pro-rata till that date)
• Name Badges - $5 each.
Name for badge 1: Name for badge 2:

Name for Badge 3: Name for badge 4:

Payment Options:

TOTAL AMOUNT OWING: $

Method of payment
Cash
Cheque (payable to The Sprite Club of QLD Inc)
Direct Deposit (Westpac - BSB No: 034002 Account No: 613033. Email us your deposit details spritecarclub@optusnet.com.au)
Credit Card (Note: will appear on statement as “Lionel Otto Instruments”)

MasterCard Visa American Express

Card No: Exp Date:

Name on Card:

I authorise the Sprite Car Club of QLD to charge my credit card with the amount listed above

Other Cars Owned:

Clicking on Submit will email your form to spritecarclub@optusnet.com.au. If you experience any problem with this, please print out page and fax to 07 3277 8520 or post to Membership Secretary, PO Box 9 Salisbury QLD 4107.