Membership Application | Mitsubishi 4WD Owners Club of WA Inc

PLEASE READ PRIOR TO COMPLETING APPLICATION

Prior to applying for membership it is compulsory to attend at least four events. This gives you a chance to see if our club suits you as well giving us a chance to get to know you.

Please feel free to contact our Membership Officer or further information.

When choosing a username please use your first initial and then lastname all lower case no spaces i.e. for John Smith use jsmith.

PLEASE MAKE YOUR PASSWORD STRONG – Passwords must contain at least two uppercase letters, two lowercase letters, two numbers, two special characters and must be 14 characters long. There is a password strength indicator to assist you, it must be green for your password to be accepted.

All fields with a red asterisk are required.

Choosing not to pay using the PayPal checkout system may cause delays in your membership being processed.

New User RegistrationChoose a Username*

Terms and Conditions*

Password*

Confirm Password*

Password Strength

Strong Password Required

First Name*

Last Name*

Do you have a valid drivers licence?*

Yes
No

Occupation

Name Badge*

Email*

Confirm Email*

Phone Number*

Date of Birth*

Partners First Name

Partners Last Name

Partners Occupation

Partners Name Badge

Partners Email Address

Partners Phone Number

Partners Date of Birth

Address 1*

Address 2

City*

State*

Post Code*

Vehicle Make*

Vehicle Model*

Vehicle Colour*

Vehicle Year*

Where did you hear about our club?*

Primary In Case of Emergency contact name

What is their relationship to you?

What is their phone number?

Secondary In Case of Emergency contact name

What is their relationship to you?

What is their phone number?

List your first club event and the date attended.*

List your second club event and the date attended.*

List your third club event and the date attended.*

List your forth club event and the date attended.*

Membership Type*

*Required field

PLEASE NOTE: This application will not be considered unless attendance at 4 events, this can be made up of two meetings and two club trips or 3 trips and 1 meeting etc. and payment is submitted.