ABN: 85 961 321 518

Membership Renewal / Application / Change of Details

To join the club, print this page, fill it in and send it along with a payment for  the appropriate fee to :-
(Cheque or Money Order only - Please DO NOT send cash)

Peugeot Car Club of Victoria Incorporated
P.O. Box 1263,
Camberwell, Vic
3124

Please Indicate if:

Renewal New member application Change of details
(Please tick one only - if renewal or change of details, please attach old address label.)
Name: ..............................................................................................................................
Address: ..............................................................................................................................

..................................................................................

 Postcode:............
Phone: Home:......................... Work:......................... Mobile:.........................
Occupation: ..............................................................................................................................
Email: ..............................................................................................................................
Associate Details
Names of Adult Associate Members: (1).................................................................
(other members of family etc. at same address) (2).................................................................
(3).................................................................
Names of Junior Associate Members Date of Birth
(family members under 18 years of age on July 1) (1).................................................... ...../...../.....
(2).................................................... ...../...../.....
(3).................................................... ...../...../.....
PAYMENT DETAILS
Years of Full Membership Required:
(tick one)		 1 year ($60.00)
2 years ($120.00)
3 years ($180.00)		 $ ..............................
Add $15.00 per year per Associate $ ..............................
Add $10.00 joining fee if new member:
(or if membership lapsed more than 12 months)		 $ ..............................
Cheque or money order should be payable to "Peugeot Car Club of Victoria Inc.". Do not send cash

Total Payment Enclosed

 $ ..............................
 

I hereby agree to be bound by the Rules and Bylaws of the Peugeot Car Club of Victoria Inc.
(New members will be proposed by the President and seconded by the Secretary, subject to acceptance by the Committee)

Signature: ................................................................   Date: .........................

Can we publish these details in the next membership list? Yes    No

Please list Peugeots currently owned (if more please attach list)

Model

Body Type

Year

Reg. No.

Owner (if Associate)
         
         
         
         
         

 
I hereby agree to my name, address, phone number and car registration numbers being published in Torque as a membership list for the information of club members.  YES NO

• Please allow up to six weeks for processing.

• Send this form with remittance to the club’s address listed above