Surname *
Christian Name(s) *
Prefix * MrMrsMs
Preferred Name
Date of Birth *
Occupation
E-Mail Address *
Residential Address *
Postal Address (if different from above)
Primary Phone Number *
Business Phone Number
Mobile Phone Number
$85.00 Senior Membership (aged 17 & over on 1st July)
$55.00 Student Membership (aged 17-23; school pupil or full-time tertiary course))
$55.00 Affiliate Membership
$45.00 Social Membership
$25.00 Junior Membership (aged 16 & under on 1st July)
$150.00 Family Membership (consists husband & wife / partner only)
+ $25.00 Per Junior Incl. On Family Licence
Name of Wife / Partner
Child #1 Name
Child #1 D.O.B
Child #2 Name
Child #2 D.O.B
Child #3 Name
Child #3 D.O.B
Boat Name
Boat Make
Boat Length
Boat Call Sign
Are you a member of any other Club? * YesNo
Other Club Name (if applicable)
State Your Full Name As Signature *
Date Of Agreement *
Nominators Name
Nominators M/ship No.
Seconders Name
Seconders M/Ship No.
