Liverpool FC Supporters Club Gauteng - Membership Application Form - DOC - DOC

							                                          LIVERPOOL F.C. SUPPORTERS CLUB
                                                            GAUTENG BRANCH - SOUTH AFRICA
                                                                           PO BOX 2062
                                                                          BEDFORDVIEW
                                                                                2008
                                                                         FAX: 0866 972 932
                                                          E-MAIL: supportersclub@liverpoolfc.co.za
                                                               WEBSITE: www.liverpoolfc.co.za
                         MEMBERSHIP APPLICATION/RENEWAL FORM
DETAILS               MAIN APPLICANT           FAMILY APPLICANT 2          FAMILY APPLICANT 3           FAMILY APPLICANT 4

Membership
Number (if
existing
member)

SURNAME

FIRST NAME


IDENTITY No.


BIRTH DATE

POSTAL


ADDRESS




POSTAL CODE

HOME PHONE

WORK PHONE


CELL PHONE


E-MAIL


          SUBSCRIPTION FEES FOR THE 2009/2010 SEASON - 1st August 2010 to 31 July 2011
INDIVIDUAL MEMBERSHIP:                               * JUNIOR (UNDER 18)                - R100.00 [ ]
                                                     * FULL (ADULT)                     - R180.00 [ ]
FAMILY MEMBERSHIP:                                   * (MAXIMUM 4 MEMBERS) - R250.00 [ ]


POST MY CARD(S)                [Y]     [N] (Please cross appropriate box)
                     PAYMENT MAY BE DONE BY CHEQUE, DEPOSIT OR DIRECT TRANSFER
Note: All non-Gauteng Residents will have their cards posted to them by default. For those in Gauteng, it is
preferable that you collect your card at meetings and/or games. However, should you wish to have it
posted and it gets lost, you will incur the cost of a new card being created. UNCOLLECTED CARDS WILL
BE DISPOSED OF AT THE END OF THE SEASON.

Crossed cheques are to be made out to: Liverpool F C Supporters Club and handed in person to a committee member at games
(please add R10 for deposit fee).

Deposits and transfers: Standard Bank, Eloff Street, Account 000836982, Branch Code 001305.

Note: Please ensure YOUR NAME appears on the deposit slips and internet banking beneficiary reference.
If paying by deposit or transfer please fax application form & deposit or transfer slip to above fax number.

               I HEREBY AGREE TO ABIDE BY THE RULES, REGULATIONS AND CONSTITUTION OF THE CLUB



                 Signed:……………………………………………………….. Date:…………………
                           LIVERPOOL F.C. SUPPORTERS CLUB – GAUTENG BRANCH SOUTH AFRICA