Membership Form

Membership Form - v2

New Member *

Yes (joining fee of $10)

Racing *

Non Racing 1/2 Year ($10)

Non Racing Full Year ($20)

Racing 1/2 Year ($30)

Racing Full Year ($60)

* To be eligible for RED PLATE you must be a full time member (no half yearly)

RED Plate

Full Year ($60)

Family Membership

Family Membership 1/2 Year ($30)

Family Membership Full Year ($60)

Allows up to 3 additional family members

Name *

First Name

Name *

Last Name

Date of Birth *

Email Address

Phone Number *

Current Ambulance Membership *

Address *

Suburb *

Postcode *

MA Licence Number *

MA Licence Expiry Date *

Next of Kin *

Next of Kin Contact Number *

Family Member Name *

First Name

Name *

Last Name

Relationship with Primary Member *

Family Member Name

First Name

Name

Last Name

Relationship with Primary Member

Family Member Name

First Name

Name

Last Name

Relationship with Primary Member

Membership Fee Total ($AUD)

Securely PAY by Credit Card

HMRAV

Historic Motorcycle Racing Association Victoria

Membership Form