Please print this form, then complete & send with remittance to:
The R & S SERIES VALIANT CAR CLUB
P.O Box R 124, Roselands, N.S.W, AUSTRALIA 2196
http://www.1962valiants.com

INTERNET APPLICATION FOR MEMBERSHIP

Cost of membership is $50.00 AUD made payable to the "R&S SERIES VALIANT CAR CLUB", and $25 if paying for 6 months. If you are applying to join from outside Australia, please add $ 10.
( If possible members are encouraged to include a photo of their car for our Club Album )

PLEASE NOTE - membership fees are due on 1st September each year.
If you are applying after 1st March, then 6 months subscription may be paid.

Surname: First Name:
 
Address:
 
Post Code : State: Country:

Home Phone:- Work Phone:-

Mobile: E-mail :             

DETAILS OF VEHICLE/S ( If more than one vehicle please use extra forms ):-

Model:- Make:- 
 
Colour :-  Body Style : Rego No : 
 
Body No.:--  Engine No.:-  Chassis No.:- 
 
 Original Extras Fitted ( ie heater, Radio ):-
 
Modifications (if any):-
 

Signed:                         Date  :        /        /20....