Social Membership Application Form

Social Membership Application Form
Name *

Prefix First Name Middle Name Last Name
Gender *
Date of Birth *

- Day - Month Year
Date
Mobile Phone Number *
Mobile number
Email *
example@example.com

Postal Address *

Street Address
Suburb
City	State
Post Code	Country

Privacy Statement

We will not use any of the above information on this form without your specific permission in writing other than to record you as a member or to communicate with you.
I'm happy to receive information relating to electronic gaming machines *

Yes No
Should be Empty:

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