SouthEast Queensland Mini Buggy Club

SEQMBC Membership Application
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Please complete this form and we will contact you either by phone or email .

Required Information *

Your Name: *

NickName (if applicable):

Date of Birth:

dd mm yy

Address:

Phone Number:

Mobile Number:

Fax Number:

Email Address: *

Next of Kin:

Next of Kin Contact No.:

Buggy or Engine type:

Nominator:

I agree to pay the nominated twelve month membership fee of $100:00. I also agree to abide by all SEQMBC constitutional rules and edicts. I will not hold SEQMBC or any member responsible for any damage done to myself or vehicle at any club related events! I agree that I will be there on my own accord and at my own risk!