Patriots Australia Inc.
Melbourne Chapter
Social Motorcycling Club
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Form - Membership Application
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Membership Application Form
Do not enter anything in this text box otherwise your message will not be sent!
Personal Details
Given Name
*
Surname
*
Club Nickname
Citizenship
*
DOB
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
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31
Year
2012
2011
2010
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1931
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1928
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1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Postal Address
*
Phone (H)
Phone (M)
Email
*
General Details
Patriots Membership
*
Full Membership
Supporter
Aware of Fee Cost?
*
Yes
No
Member of a MC?
*
Yes
No
If yes, which one?
Transferring from
Motorcycle Make
Aprilia
BMW
Cagiva
CZ
Ducati
Harley-Davidson
Honda
Hyosung
Indian
Jawa
Kawasaki
Moto Guzzi
MV Agusta
Norton
Suzuki
Triumph
Yamaha
Motorcycle Model
Engine Capacity
Under 249 cc
250 - 499 cc
500 - 749 cc
750 - 999 cc
1000 - 1499 cc
1500 + cc
Rego Number
License Class
Open
Restricted
Abide by Club Rules?
*
Yes
No
Military Service Details
Military Service
Navy
Army
Air Force
Reserves
Foreign Military
Service Number
Overseas Service?
Yes
No
Medals/Ribbons?
Yes
No
Proof of Service
Application Date
*
Signature
OFFICE USE ONLY
Proof Of Service Seen
Date Fees Paid
Payment Type
Cash
Cheque
Money Order
Direct Deposit
Nomination Date
Probationary Date
Full Member Date
Membership Number:
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