Name:

Trading Name:

Store(s) Nominated for Membership:

Address:

Post Code:

Phone Number:

Fax Number:

Email Address:

Subscription Fee Structure:
Financial year 1st july to 30 june

First Store $198.00 (including GST)
Additional stores $94.00 (including GST) per store

All stores nominated must be fully or partly owned by the applicant.
Owner/Managers of indivdually owned franchise stores must make individual applications.

Please debit my card for the amount of being for membership subscription for store(s) nominated above.

Please Select One Visa Master Card Bank Card

Name On Card:

Card Number:

Expiry Date: