Membership – Laangspeedwayclub

Membership form

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First Name

Last Name

Email

Phone

Address

Town

P/Code

Select item

Family Membership (2 Adults & Children under 16 years old) - $75.00
Single - $35.00
Life Member - $5.00

(Please list below family member details)

Member 1

Surname

Given Name

Date Of Birth

Speedway Aust License No

Speedway Aust Expiry Date

Add More Members

Yes
No

Speedway Aust Of

Competitors Only

Driver Name

Class/ Category

Car Number

VSCF License No

VSC License No

Speedway Australia License No

Direct Deposit to Laang Speedway Club BSB: 633000 Account No: 161893946 Bank: Bendigo
Please put name as reference on payment or advise what reference is on payment