Membership

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MEMBERSHIP FORM

INDIVIDUAL / CLUB DETAILS

NAME:  ……………………………………………………………………………………

ADDRESS:  ………………………………………………………………………………..

PHONE   B/H:  …………………………………A/H:  …………………………………..

MOBILE:  ……………………………EMAIL:  …………………………………………

VEHICLE  DETAILS  (continue on the reverse if insufficient space)

MAKE:  …………………………………..MODEL:  ……………………………………

YEAR:  ……………………BODY STYLE:  …………………………………………….

REGO NUMBER:  …………………………SHOW/ STREET:  ……………………….

 

MEMBERSHIP INFORMATION

Please tick one          INDIVIDUAL  $15.00 1           CLUB MEMBER  $10.00 1

Please tick one   New Member 1  Renewal 1  Membership Number:  …………

Name of Club (if applicable):  …………………………………………………………….

Club Postal Address:  ……………………………………………………………………..

……………………………………………………………………………………………….

Newsletter Subscription for Individuals/Club Members:    Extra  $5.00 YES / NO

                                                                                                                                                                                              Strike out which is not applicable

Postal Address for Newsletter:  ……………………………………………………………

………………………………………………………………………………………………..

VSMA STICKER                          Please Select Colour Required

1  White  1  Black  1  Yellow  1  Red  1  Blue  1  Green  1  Orange  1  Magenta

1  Burgundy  1  Other (if available)  Please specify ……………………………………

PAYMENT INFORMATION

Please make cheques/money orders payable to the V.S.M.A.

Amount Enclosed:      $ ……………….     Cash / Cheque / Money Order

                                                                                                                                Strike out which is not applicable

 

OFFICE USE ONLY  Entitlement:

1  VSMA Patch 1  Year Patch   1  Membership Card  1  VSMA Sticker

Comments: ……………………………………………………………………………………………….