2012
Application for Membership
PO
Box 307
Mtunzini
3867
| Contact: |
Zelda Flook |
|
Tel: |
035 340 23 71(H) or 084 814 4551 |
| Fax: | 086 231 2325 |
| email: | zeldaf@telkomsa.net |
|
|
Annual
Club Membership Fee |
Annual
KZN Athletics |
Annual
Cycling SA Membership Fee (Cyclists) |
|
Adult |
R200 |
R80 |
R75
plus R35 KZN provincial fee (Done by member online) |
|
Junior |
R50 (Must be turning 19 or younger in 2012) |
R50 |
As
above |
Banking Details: First National Bank, Empangeni; Account no: 62098106125; Branch code: 220130
|
Name and Surname |
||
| ID
number |
||
| Date
of Birth |
||
| Sporting
Discipline (X) |
Running: |
Cycling: |
| Previous
Licence Number |
||
| New
Licence Number |
||
Postal Address
|
|
|
Residential Address
|
||
| email |
||
| Telephone
Numbers |
Work: |
Home: |
| Cell: |
Fax: |
|
I
declare that I am physically and mentally fit and that the Mtunzini Athletic
Club
will not be held responsible for any loss or injury suffered by me for
any reason whatsoever.
| Signature: (Member or Parent) |
|
Date: |