NSW UTE CLUB Membership Application
FULL Membership FULL MEMBERSHIP MEMBER NUMBER_____________________
Name:
Date of birth:	Mobile:	Phone:
Current address:
City:	Post Code:	License No:
Ute Model:	Registration No:	Ute Colour:
associated membership Spouse/Family member Information MEMBER Number_______________________
Name:
Date of birth:	Mobile:	Phone:
Current address:
City:	Post Code:	License No:
PROSPECTIVE/honorary membership PROSPECTIVE/honorary member Information MEMBER Number_______________________
Name:
Date of birth:	Mobile:	Phone:
Current address:
City:	Post Code:	License No:
Ute Model:	Registration No:	Ute Colour:
Emergency Contact
Name of a relative not residing with you:
Mobile:	Phone No:
Relationship:
Club Fees: Full Member: $25.00 Associate member: $15.00 Honorary member: $15.00 Prospective member: $15.00
Signature of applicant 1:		Date:
Signature of applicant 2:		Date: