BERRIMA HORSE TRIALS INC.

MEMBERSHIP APPLICATION FORM

Membership runs from 1^st January to 31 December.

Please send this form, with your remittance to:

Tina Stafford Ph/fax 02 4868 1285

B.H.T. Secretary Email: scoopful@hinet.net.au

P O Box 624

MOSS VALE NSW 2577

SUBSCRIPTION RATES

Single Member $30.00

(For one individual)

Family Membership $50.00

(2 adults & children up to 17 years)

Junior Member $20.00

(for one individual up to 17 years)

Working Member Free

Members are entitled to membership of the Southern Highlands Jump Club, discounted entries at Berrima Horse Trials clinics and copies of newsletters.

Please find enclosed a cheque / money order for $……………..for membership of Berrima Horse Trials Inc. for the period of 1 year. (Cheques made payable to Berrima Horse Trials Inc.)

YEAR:……………………………

MEMBER’S TITLE: ( Dr,Mr,Mrs,Miss,Ms,)…………………………………………………………………

SURNAME:……………………………………………………………………………………………………….

FIRST NAME:…………………………………………………………………………………………………….

ADDITIONAL FAMILY MEMBERS: (for children under 17, please put age.)

……………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………….

EMAIL: ……………………………………………………………………………….

POSTAL & RESIDENTIAL ADDRESS:……………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………..…………………………………………………………………………………

TELEPHONE: Home…………………………………………………………………

Business…………………………………………………………….

SIGNED:………………………………………………DATE:……………………….