[Please print & complete form & forward to address below]

MEMBERSHIP APPLICATION

Membership Fee : $25.00

NAME: Surname……………………First Name…………………Middle Name…………………

Title……….(Mr, Mrs, Ms)    Sex…………….(Male/Female)   Date Of Birth…………………..

ADDRESS:……………………………………………………………………………………………

………………………………………………………………POSTCODE…………………………..

Q Squash Affiliation number (if known)……………………………

(If not affiliated own insurance should be taken out)

Phone: (Home)……………………………..(Work)………………………………

             (Mobile)………………………(E-mail)……………………………………..

Club…………………………………………Grade………………Position………………………..

Do you wish to receive your newsletter via email        Yes………… No……………

I, the undersigned, hereby make application for admission as a Member of the Queensland

Masters Squash Association Inc.

If accepted, I agree to abide by the rules and regulations set down by the Association.

Signature……………………………………………..Date…………………………….

PLEASE FORWARD THIS APPLICATION TOGETHER WITH PAYMENT OF $25.00 TO:

Mr Peter Knauth                                                  EFT DETAILS

Treasurer, QMSA                                                BSB: 124074

37 Osanna Street                                                 ACC. NUMBER 10487588

DAISY HILL QLD 4127                                      USE NAME AS REFERENCE

PLEASE MAKE CHEQUES PAYABLE TO :-

QUEENSLAND MASTERS SQUASH ASSOCIATION INC.