WIDE BAY BURNETT 4X4 CLUB INC,  PO BOX 414,  HERVEY BAY 4655
APPLICATION FOR MEMBERSHIP

SURNAME PARTNERS SURNAME
FIRST NAME PARTNERS FIRST NAME
ADDRESS
POSTAL ADDRESS
PHONE HOME   WORK   MOBILE  
EMAIL
OCCUPATION PARTNER OCCUPATION
DATE OF BIRTH PARTNER DOB
NAME OF CHILDREN
DOB DOB
DOB DOB          
DOB DOB
I/We certify that my/our vehicle does have at least Third Party Property Damage Car Insurance, is registered and is in a Roadworthy condition and I/We accept full responsibility of such insurance as well as my/our driving ability. I/We certify that I/We are holders of a valid and current drivers license and I/We accept that if we lose the use of my/our drivers license I/We shall not participate as a driver in any club event until such times as I/we have my/our drivers license returned. I/We undersigned acknowledge receipt of the Clubs By-Laws. I/We understand that I/We are required to read the Clubs By-Laws and follow them to the best of my/our ability. I/We understand that the Committee Members are available at anytime to give me/us a full meaning of the interpretation of the By-Laws. I also understand that all the general road rules and regulations must be followed.
APPLICANTS SIGNATURE   DATE
PARTNERS SIGNATURE   DATE
EMERGENCY CONTACT NAME PHONE NUMBER
MEMBERSHIP TYPE       FAMILY $55           SINGLE $50
Nomination Fee $20 ( once only fee for all new applicants)
Annual membership renewal is on 1st February of each year
Members introduced to the Club after 1st August pay half annual fee.
Acceptance of Membership application is subject to approval by the Management Committee
VEHICLE DETAILS
MAKE   MODEL MOTOR Petrol Diesel GEARBOX Manual 
Auto
REGISTRATION    YEAR     NUMBER OF YEARS A 4WD OWNER 
VEHICLE ACCESSORIES AND RECOVERY EQUIPMENT
UHF Radio    GPS   Front Tow Point   Rear Tow Point   Snatch Strap   Hi Lift Jack   Air Lift Jack
Hand Winch  Bullbar Rear Bars    Side Steps  Roof Rack      Traction Aids        Fire Extinguisher   
Suspension lift kit       Body Lift Kit   Diff Lockers  Dual Battery   Long Range Fuel Tank    Snorkel    Driving lights
FIRST AID CERTIFICATE NO  YES  Details
4WD EXPERIENCE
SAND       MUD       DIRT      SNOW     DESERT     WATER CROSSING    HILL     ROCK
HAVE YOU EVER ATTENDED A 4WD AWARENESS OR TRAINING COURSE?         YES    NO
WHERE DID YOU HEAR ABOUT THE CLUB?
Newspaper      Internet     Friend      Yellow Pages   Other Local Business   
This Club is a member of the Queensland Association of Four Wheel Drive Clubs Incorporated (QAFWDC) and affiliated with the Australian National Four Wheel Drive Council.
Disclaimer: This information will not be distributed to any mailing agencies but will be available for Club use only.