Membership Application

CANTERBURY LEAGUE CLUB LIMITED • ABN 84 000 191 248

18 Years Old

110 Years Old

Form Types

PERSONAL INFORMATION

Title

Gender

First Name

Surname

Middle Name

Preferred Name

Date of Birth

You must be 18 years of age or older to join. Please include the forward slashes / when entering the date.

DETAILS

Home Phone

For Australia/New Zealand numbers, please ensure that they are valid

Mobile Phone

If you do not have a mobile, enter your landline including the area code.

Mobile Phone

For Australia/New Zealand numbers, please ensure that they are valid

COMMUNICATION PREFERENCES

Offers & Competitions (Canterbury Birthday Dollars; Entertainment; F&B Promotions; Competitions)Membership News (Renewals; AGM notices, Changes to membership notices)C-Life Health Club News

I wish to receive information about gaming promotions.

YesNo

COMMUNICATION CHANNELS

EmailSMSMail

Occupation

Do you speak a language other than English at home?

YesNo

Language spoken

Do you support the Canterbury-Bankstown Bulldogs?

YesNo

RESIDENTIAL ADDRESS

Country

Full Address

Street Address

Suburb

Postcode

State

Would you like to enter a different postal address?

Yes

POSTAL ADDRESS

Country

Full Address

Street Address

Suburb

Postcode

State

PROOF OF IDENTITY

ID Type

ID Number

VERIFICATION

By checking this box I verify that I have digitally signed this membership form.

PRIVACY STATEMENT

We generally collect your personal information for the purposes of processing your membership application and administering your membership. Unless you advise us otherwise we will also provide you with information related to your membership which we believe will be of relevance or interest to you. If you would like further information on Canterbury’s Privacy Policy including details of how you can access your personal information held by Canterbury, a full copy can be obtained online at www.canterbury.com.au

Club Options

CanterburyLakembaMoxon

MEMBERSHIP CATEGORY

Membership

1 Year Ordinary Member - $5.005 Years Ordinary Member - $20.00

Total Payment

Email Validation

Mobile Phone Validation

Mobile Phone + Country Validation

Home Phone Validation

Home Phone + Country Validation

PAYMENT

PAYMENT INFORMATION

Name on Card

Type

Card Number

CVC

Expiry Date

Card Expiry Month in MM format

Card Expiry Year in YY format