Membership Application Form

2013 membership application form

Members Name_______________________________________________________

Partners Name________________________________________________________

Address    _____________________________________________________________

     _____________________________________________________________

Phone ________________________________Mobile________________________

E-mail ______________________________________________________________

I acknowledge that by becoming a member of the Wallan Football & Netball Club

I   have read and understood the Club code of conduct as displayed on the Clubs Website http://www.wallanmagpies.com.au/ Membership Page and will abide by it at all times   

Signature.... X_________________________________________________________

I would like to volunteer to assist the Club during the season,  Yes____ _No______

Payment by Cheque, send to Wallan Football and Netball Club together with this application form to P.0.Box 127 Wallan Vic 3756

Payment by Credit Card

Credit Card Type,      ( please Tick, Visa______   Mastercard ________

Credit Card Number____________________________________________________

Account Name ________________________________________________________

Expiry Date______________CCV_________Amount $________________

Name on Card________________________________________________________

Signature X___________________________________________________________

 * Credit Card Verification number

               In order to process payments with a credit card, we need your credit card verification number. This number is used to establish that you are in possession of the card used for the payment. The verification number is a 3 digit number printed on the back of your credit card. It appears after and to the right of your credit card number

Direct Debit Details Wallan Football & Netball Club

  BSB 633-000   Account 132923830