Form Test

Member Number*

Name*

Title

First

Last

Email*

Email confirmation*

Has your residential or postal address changed?*

Yes

No

Residential Address

Street Address City/Suburb State/Territory Postcode

Postal address?*

Postal Address

Street Address City/Suburb State/Territory Postcode

Have any of your phone numbers changed?*

Yes

No

Home or Main Phone*

Mobile Phone

Have any of your contact details changed?*

Yes

No

Partner Name

Emergency Contact

Emergency Phone

Select Membership Renewal/Change Type*

Associate/ordinary membership with vessel rescue coverage ($76)

Associate/ordinary membership without vessel rescue coverage ($27)

Family Membership with vessel rescue coverage ($87)

Family Membership NO rescue coverage ($38)

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Details

Donation Amount

Note: Donations of $2 or more are tax deductible.

Total to Pay (incl. GST)