Corroboree reccie.

Title

First Name *

Last Name *

Email Address *

Billing Address *

Suburb *

State *

Postcode *

Country *

Home Phone Number *

Work Phone Number

Mobile Number

Occupation

Date of Birth

Joining Date

First Aid Certificate Date

Club Member who introduced you

How did you hear about us? *
TLCC QLD Magazine Advertised Article Show or Exhibition Search Engine Member Other

Partners Information

Partners First Name

Partners Last Name

Partners Address

Partners Suburb

Partners State

Partners Postcode

Partners Date of Birth

Partners Occupation

Partners Home Phone

Partners Work Phone

Partners Mobile Phone

Partners Email Address

Partners First Aid Certificate Date

Vehicle Information

Vehicle Make 1

Vehicle Model 1

Vehicle Year 1

Vehicle Rego 1

Vehicle Colour 1

CTP No.

CB Call Sign (if you have one)

Family Information

Child 1 First Name

Child 1 Date of Birth

Child 2 First Name

Child 2 Date of Birth

Child 3 First Name

Child 3 Date of Birth

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Address

Members Zone Access

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Username *

Password *

Confirm Password *

Membership Type

Membership Price based on todays date *
October 1 to June 30 - $90 per family
November 1 to June 30 - $80 per family
December 1 to June 30 - $70 per family
January 1 to June 30 - $60 per family
February 1 to June 30 - $50 per family
March 1 to June 30 - $40 per family
April 1 to June 30 Next Year - $120 per family
July 1 to June 30 - $120 per family

I / We hereby wish to apply for membership in the Toyota Landcruiser Club (QLD) Inc. If this application is successful, I / We agree to read and abide by the club’s Constitution, Rules and Regulations, and By‐Laws. (These documents can be made available upon request and are also available on our website at www.tlccqld.com.au. ) I / We also agree to ensure my / our vehicle is maintained in a road worthy condition.

Membership Payment

Payment Method *
Credit Card Cash EFT

Name on Card *

Card Number *

Card Expiry *

Card Type *

CCV Number *

Amount *

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Privacy
From time to time, we, the TLCC Qld(Inc) may use members names and pictures in Advertising and Promotion of the club on mediums such as Magazines, Flyers, Radio advertising, Television Advertising, Online Social Sites such as FACEBOOK. By submitting this form, you are authorising the use of this information for the purposes stated above. If, for some reason you do not want this to occur please email secretary@tlccqld.com.au with particulars.

Corroboree reccie.

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