I*

(Full Name of Applicant)

Of *

(Address)

City* State *

Postcode *

Desire to become a member of the Benalla Auto Club INC.

Date of Birth: / / *

Occupation:

Employeer:

In the event of my admission as a member, I agree to be the rules

of the Benalla Auto Club Inc. for the time being in force.

Agree Disagree

Membership $70 Australian.

Master Card Visa Bankcard *

Credit Card No:*

Expiry Date:

Other Information you Wish to provide