Mckell Place & 236 Auburn St Goulburn NSW 2580

Telephone (02) 4821 3355 Facsimile (02) 4821 8384

APPLICATION FOR MEMBERSHIP

Mr./Mrs./Ms Surname_____________________________________ GIVEN NAMES____________________________

Postal Address_________________________________________________________________________________

Local Address IF DIFFERENT FROM POSTAL ______________________________________________________________

q Male    q Female                            Date of Birth_____________/_____________/____________________

Home Phone_______________________________    Work Phone ______________________________________

Drivers Licence No._____________________________   Occupation ____________________________________

Are you interested in joining our  q Day Out Society  q Fishing Club

Signature_____________________________________  Date _________________/____________/_____________

I hereby apply for membership of the Goulburn Workers Club and if accepted, I agree to abide by the rules, constitution, and by-laws of the Club.  I am over the age of eighteen.

Proposer M/ship No._____________________ Signature ______________________________________________

Seconder M/Ship No ____________________ Signature ______________________________________________

Both Proposer and Seconder must of been members for longer than 12 months.

ANNUAL MEMBERSHIP $8.00 (GST INCLUDED)

False Information on application means expulsion.  Application for membership must be accompanied by proof of age for persons under 25 years of age.

PRIVACY STATEMENT

The Goulburn Workers Club is subject to the provisions of the Privacy Act 1988.  The personal information provided by you on this application will be used to process your membership application.  Failure to provide all of the requested information may result in your application being rejected.  You have the right to access and correct any of your personal information that the club hold about you.

The Club does not usually disclose your personal information to any other organisation or person unless there is a legal requirement to do so.  The Club may disclose your information to third parties that provide services under contract to the Club.  These contracts require the third party to keep your personal information confidential and secure.

Your personal information, including information about you obtained as a result of you placing your membership card in a gaming machine or other club machine (not ATMs), may be used by the Club for marketing purposes to improve our services and to provide you with the latest information about those services and any new services and promotions.

Please tick box if you do not wish to receive marketing material and information about our promotions and services.

q  Yes    q No

Signature_____________________________________ Date _______________________________________________