First Name*
Last Name*
Email Address*
Street Address*
Suburb*
State* NSWQLDVICACTTASSAWANT
Country*
Mobile Number*
Date of Birth*
Membership Type* Please Select$180 - Eddie Robinson Package$110 - Jim Burke Package$65 - Keith Miller Package
Business Name
Manly Mates Rates
Website
Business Address
Business Email
Business Phone Number
Merchandise* Please SelectCapPolo Shirt
Shirt Size Please SelectSmallMediumLargeX Large2 XL
Payment Type* Please SelectBy ChequeBy Direct DepositBy Credit CardLife MemberOther
Please make all cheques payable to MWDCC and mark clearly with your full name on the reverse. Please mail all cheques to PO Box 1239, Manly NSW 1655.
Please deposit your subscription fee into the below bank account. For the description, please use your first name initial, surname & "Manly BB" (i.e. "D Gainsford Manly BB"). Bank details are: Bank of Queensland (Manly) - Account Name: MWDCC - BSB: 122 712 - Account Number: 2074 3076
You will be contact by the club shortly after submitting this application to take your credit card details over the phone.
Comments
Applications will only be processed once payment is received within five (5) working days. Please note that Blue Blood Membership is free for all MWDCC Life Members, although payment will be accepted. You will be sent a copy of this e-form when you hit 'Submit'. If this does not arrive, please contact us directly.
First Name
Last Name
Email address: