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Probus Club Membership Application Form – Australia 


I hereby apply for membership of the Probus Club of                                                ____                               (the Club)

Title:                                           Surname:                                                                                               

 Given Names:                                                                              Preferred Name on Badge:                   _______        

Spouse/Partner Name:                            _____________               

Date of Birth          /          /         Email Address:                        _______________________________________     

Address:                                                                                _______________________    Postcode:                  

Telephone:                                                                                   Mobile:                   ____________                

Former Vocation:                                                                                                                      ___________

                                                                                                                            ________                        

 Hobbies, Sporting & Other Interests:                                                                                                                            

                                                                                                                                                  _                             

In case of emergency, please contact:                                                                                                                           

Emergency Contact Telephone:                                                                           _______________           ________     

                                                                                                     _________________________________                 

                                                                                                                  ___________________________________

  • 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.
  • 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 the information provided in this application form will be provided to Probus South Pacific Limited (PSPL) in accordance with the PSPL Privacy Policy which can be viewed on the PSPL website.
  • I understand that the minimum information required by PSPL is my first name and last name and that it is my responsibility to advise the Club Secretary in writing if I do not want PSPL to hold any of the additional information in this application form or I do not wish to be contacted by 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 and/or on social media 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 understand that the Club Secretary may provide photographs of its members for use in PSPL’s publications, website and/or social media. 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 receive the Active Retirees E-newsletter published by PSPL and understand that I can unsubscribe from the E-newsletter at any time.

Applicant’s Signature                                                                              _____________          Date:              ___   __ 

Sponsored by*:                                        ______         Signature:               _______                Date:             ____        

Sponsored by*:                                                ______ Signature:                                            Date:                            

*MEMBERSHIP APPLICATIONS MUST BE SPONSORED BY TWO FINANCIAL MEMBERS OF THE CLUB. FOUNDATION MEMBERS OF NEW CLUBS DO NOT REQUIRE SPONSORS. 

 
   

 Issued by Probus South Pacific Limited ACN 152 374 395 – May 2018

 

 

 


 

                        HOLLYWOOD KINGS PARK PROBUS CLUB

                                             CLUB USE ONLY  

 

Payment Administration Details

 

Membership Number ____________________

 

Joining Fee

 

 

 

 

 

Date

Amount $

 

 

 

 

 

Cash

 

 

 

 

Card

 

 

 

 

Direct Credit

 

 

Subscription

 

 

 

 

 

Date

Amount $

 

 

 

 

 

Cash

 

 

 

 

Card

 

 

 

 

Direct Credit

 

 

Single (Annual) Payment – Morning Tea

 

 

 

 

 

Date

Amount $

 

 

 

 

 

Cash

 

 

 

 

Card

 

 

 

 

Direct Credit

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

Direct Credit Account Details

Hollywood Kings Park Probus Club

BSB:       302-162               Account No:       1454476