2015 Application for Membership
PO Box 307
Mtunzini
3867

Contact:

Zelda Flook

Tel:

035 340 2371(H) or 084 814 4551
Fax: 086 239 0416
email: zeldaf@telkomsa.net


Annual Club
Membership Fee

Annual KZN Athletics
Licence Fee (Runners)

Annual Cycling SA
Membership Fee (Cyclists)
Adult
R200
R100
R75 plus R35 KZN provincial fee
(Done by member online)
Junior
R50
(Must be turning 19 or younger in 2015)
R60
As above

Banking Details: First National Bank, Empangeni; Account no: 62098106125; Branch code: 220130

 Name and Surname

 
 ID number

 
 Date of Birth

 
 Sporting Discipline (X)

 Running:

 Cycling:

 Previous Licence Number

 
 New Licence Number

 

 Postal Address

 

 

 Residential Address

 


 email

 
 Telephone Numbers

 Work:

 Home:
 Cell:

 Fax:

I declare that I am physically and mentally fit and that the Mtunzini Athletic Club
will not be held responsible for any loss or injury suffered by me for any reason whatsoever.

Signature:
(Member or Parent)



Date: