QLD FB-EK HOLDEN CAR CLUB INC MEMBERSHIP APPLICATION
(Please print out this form and fill out.)
Applicants Details:
Name: __________________________________________________________________
Street: _________________________________________________________________
City: ___________________________________________________________________
State: ____________________________________ Postcode: ______________________
Home Phone Number: ____________________ Work Phone Number: ___________
Membership Class: (circle one) Single/Family/Distance (+ 200km from Brisbane GPO)
Vehicle Details:
First Vehicle Details: _____________________________________________________
Year: ________ Model: __________ Body Type: ___________ Colour: ______________
Engine Number: _____________________ Chassis Number: ______________________
Full Rego Number: _________________ Club Rego Number: ____________________
Modified: Please circle one Yes No
Details of Modifications: ___________________________________________________
Second Vehicle Details: ___________________________________________________
Year: ________ Model: __________ Body Type: ___________ Colour: ______________
Engine Number: _____________________ Chassis Number: ______________________
Full Rego Number: _________________ Club Rego Number: ____________________
Modified: Please circle one Yes No
Details of Modifications: ___________________________________________________
I have read and agreed to abide by the constitution of the Qld FB-EK Holden Car Club Inc
Signed: _______________________________ Date: ____________________________
Membership Fees
Single: New Member $ 35.00 Renewal $ 30.00
Family: New Member $ 40.00 Renewal $ 35.00
Distance: New Member $ 25.00 Renewal $ 15.00
Please post completed Membership Application Form along with a cheque/Postal Note (no cash)
made payable to:
The Secretary
Qld FB-EK Holden Car Club (Inc)
PO Box 211
Cannon Hill Q
**Make sure that you also send us a note about yourself, family and car/s. On acceptance of your
membership application by the club committee, a receipt and Membership card will be forwarded to you.
Committee Use Only:
Issued with Date Initials
Membership Card: ____ ______
Constitution: ____ ______
Club Shirt: (Extra Charge) ____ ______
Sticker: ____ ______
