Please read and agree to the following conditions BEFORE completing this application form.

I agree to be bound by the provisions of the Club’s constitution, by-laws and/or standing resolutions and agree to take an active role in the Club through my attendance and participation.
• I understand that the information provided in this application will be used to assess my application and maintain my membership.
• I understand that my application may not be processed if any of the above information is not provided.
>• I acknowledge that at some time during my membership, I may be called upon to take an active role on the Management Committee and agree to do so.
• I consent to my name, address, telephone number and email address being included in the ‘Directory of Members’ to be distributed only to members of the Club.
• I understand that I may access any personal information the Club holds about me upon request.
• I accept that only my first name and last name provided in this application form will be provided to Probus South Pacific Limited (PSPL).
• I understand that the Club has Public Liability Insurance of $20 million through PSPL and that I can access a summary of this coverage through the Club Secretary or the PSPL website.
• I understand that the Club may publish photographs of its members on its website, in its newsletter, on social media and/or in PSPL publications to promote the Club and its events. By signing this application form, I consent to the publication of such photographs unless I have advised the Club Secretary in writing that I do not consent to such publication.
• I agree to pay the joining fee and annual subscription as determined by the Club
Joining Fee: $25 includes Name Badge
Annual Subscription*: $60
Pro-rata fees (if required) are available from Club Secretary

Acceptance
I agree to the above conditions. This box must be ticked before proceeding with this form.

Your Title
MrMrsMsDrProf

Your Given name

Your Surname/Family name

Name for badge

Spouse/Partner Name

Address

Telephone Number ( Home )

Telephone Number ( Mobile )

Your email

Date of Birth

Former Vocation

Particular interests

1st Emergency Contact
Name

Relationship

Phone

Alternate Emergency Contact
Name

relationship

phone contact

MEMBERSHIP APPLICATIONS MUST BE SPONSORED BY TWO FINANCIAL MEMBERS OF THE CLUB. If you don't have any personal contact with a current member of the club please enter the word ‘Nil’ in each box - the membership officer will contact you.
I am sponsored by:
I am sponsored by:

Electronic Signature
By checking this box you are signing this application. This box must be ticked before submitting this Application Form