Online Application 1st January to 31 December Membership Fee Price: 1 July to 31 December Half Year Membership Fee Price: Contact and Personal DetailsName* First Last Partner's Name First Last Phone (Mobile)Phone (Home)Phone (Work)Partner's Phone (Home)Partner's Phone (Mobile)Partner's Phone (Work)Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Partner's Email Occupation Date of Birth DD slash MM slash YYYY 4WDing and Safety DetailsDo you own a 4 Wheel Drive Vehicle?* Yes No Number of years 4WDing* Do you hold a First Aid Certificate?* Yes No Please give details about the certificateWhen does the certificate expire? DD slash MM slash YYYY Have you had 4WD Driver Awareness/Training?* Yes No Please give details about your training, including year taken*AgreementI/We certify/acknowledge: my/our vehicle does have at least Third Party Property Damage Car Insurance, is registered and is in a Roadworthy condition and I/We accept full responsibility for such insurance as well as my/our driving ability/s. I/we am/are the holder/s of a valid and current driver’s license and I/we accept that if the use of my/our valid driver’s license is lost, I/we shall not participate as a driver in any club event until such times as I/we have my/our valid driver’s license reinstated. on acceptance of Membership I/we will receive a copy of the Club’s Constitution and By-Laws. I/We understand that I/we are required to read the By-Laws and follow them at all times. I/We understand the Committee Members are available at any time to give me/us with the full meaning of the interpretation of the By-Laws. I/We also understand that all the general road rules and regulations must be followed. I/we agree the above information can be included on the Club Contact List and made available to other Club members. If paying via EFT, fees must be received within 14 days of form submission or application becomes void. Agreement* I agree to the outlined terms Payment method* EFT / Direct Deposit Club bank account details: Suncorp Metway BSB: 484 799 Account Number: 071427040 Use your name and ‘membership fees’ in the reference line. Fees must be received within 14 days of form submission or application becomes void.
