Membership Application Form
Purvis Eureka Car Club of Australia Inc.
(Incorporated in Victoria.   No A0047126B)
Please complete and post this form, together with applicable fee, to :
The Secretary
Purvis Eureka Car Club of Australia Inc.
P.O.Box 48 
O'Halloran Hill 
S.A. 5158 
Name:
Postal Address:
 ( State ) ( Post code )
Phone : (BH)   
 (AH)
(Mob)
 (Fax)
E-mail :
(Pl ease note that the majority of communication with Members will be via email)
Do you currently own a Eureka? Yes / No  	Date Acquired:
Model:
 Manufacturer :  Allan Purvis / Colleen Lo n g / P a u l Nelson / Don't know
( eg  Sports, PL3 0 , F 4, don't know ) 
Registered ?
 Yes / No  Registration No :
Have you completed details for the "Reek Register" (see details and form on the Club website) ?
How did you hear about the Purvis Eureka Car Club of Australia?
Details of Club Shirt Required:         Size:       S	M	L	XL	XXL                            
Current Fees:
Joining Fee
 $40.00
A Once -Only Fee - Includes CLUB shirt, membership card, key fob, stickers, 
Annual Subscription
 $40.00
Subscriptions are on a "financial year" basis and are due 1st July each year.
New members joining after 1st April will have their subscription extended to
30th June the following year (i.e. up to 15 months subscription)
Sub- Total $80.00
Club Merchandise:
$
Extra "My Other Car" Stickers @ $2.00	 Quantity  
 $
Extra Club Shirt(s) @ $35.00 (Include quantity, size, colour, etc)
$
Extra Key Fob @ $9.00			 Quantity
Freight/Postage 
 $
Please make cheques/money orders payable to Purvis Eureka Car Club of Australia Inc -  
TOTAL PAYABLE $
I, the above named, apply to become a member of the Purvis Eureka Car Club of Australia Inc, and in the event of my admission as a member I agree to be bound by the Constitution and Rules of the Association.
Signature of Applicant
Date
Office Use Only :
Date Admitted:
 Membership No:
 Amount Paid: $
Receipt No:
 Paid Until:
Privacy: In accordance with the provisions of the Information Privacy Act 2000, The Purvis Eureka Car Club of Australia Inc collects personal information only if the information is necessary for the Club’s administration and activities
 V  11/11
(Note: Joining fee includes postage by registered mail. Additional stickers and key fobs do not attract an extra freight/postage charge, but please include an amount of $5.00 per extra Club shirt ordered)