| Become a Club Member! GOULBURN & DISTRICT RACING CLUB LIMITED Racecourse Drive, Goulburn NSW 2580 PO Box 226, Goulburn NSW 2580 Ph: (02) 4822 2222 Fax: (02) 4822 1033 APPLICATION FOR MEMBERSHIP Preferred Title:___________ Last Name:__________________________ First Name:___________________________ Residential Address:__________________________________________________________ ____________________________________________________________________________ Postal Address:______________________________________________________________ Telephone Numbers: (BH)_____________________ (AH)____________________________ Mobile:__________________________ Email Address:_______________________________________________________________ Date of Birth:________________________ APPLICANTS SIGNATURE:............................................................ Proposer's Name........................................ Signature........................................ Seconder's Name........................................ Signature........................................ Date:........................................... MEMBERSHIP FEE $66.00 (incl GST) Entitles Member's Badge and Member's Guest Badge Please detach and return with your payment | 
