BMX AUSTRALIA CREDIT CARD APPLICATION FORM 2010 MEMBERSHIP PRICES by ypy11747

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									        BMX AUSTRALIA CREDIT CARD APPLICATION FORM

                       2010 MEMBERSHIP PRICES

                          Open Licence - $82.00
                         Sprocket Licence- $80.00
                           Club Permit - $62.00
                           Day Licence - $15.00
                            Late Fee - $20.00
                        Replacement Card - $10.00
                          Upgrade Fee - $20.00

Please attach this form with your licence application form and send it to:

                               BMX AUSTRALIA
                                PO Box 6310
                                ALEXANDRIA
                                 NSW 2015

PLEASE ENSURE THAT YOU CLUB HAS VERIFIED AND SIGNED YOUR
APPLICATION FORM BEFORE POSTING IT.

RIDER NAME:____________________________________________________

RIDER CLUB:_____ _______________________________________________

CREDIT CARD DETAILS:

CARDHOLDER:___________________________________________________

CARD NUMBER:__________________________________________________

EXPIRY DATE:__________________               CARD TYPE (please tick)
                                                  VISA
                                                  MASTERCARD
                                                  BANKCARD
AMOUNT:$___________________

SIGNATURE:

								
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