Application for Membership

I do hereby make application for membership to BMX New Zealand, I also agree to comply with all rules and regulations for all activities and understand that I am fully responsible for my actions. I understand that my membership will be valid until the 31^st July

each year, and is renewable before the expiry date.

All applicants must fully complete and sign this form before a Licence will be processed

DATE

LICENCE NUMBER (All riders racing 20” & Cruiser will be issued with two licences.)

PREVIOUS FULL 20” CRUISER

( Please enter CURRENT licence number)

NEW FULL 20” CRUISER

( Please leave BLANK for licence co-ordinator )

PREVIOUS NOVICE 20” CRUISER

( Please enter CURRENT licence number)

NEW NOVICE 20” CRUISER

(Please leave BLANK for licence co-ordinator)

FIRST NAME SURNAME

ADDRESS

CITY / TOWN

PHONE ( ) FAX ( )

Email address

SEX MALE FEMALE DATE OF BIRTH

(If new licence a copy of birth certificate MUST be produced)

(Copy of passport is also acceptable. Don’t send original)

CLUB PLATE NZ #20” CLUB #20”

PLATE NZ #CR CLUB #CR

LICENCE TYPE FULL NOVICE UPGRADE 20” CRUISER

ETHNIC ORIGIN EUROPEAN MAORI OTHER

Office Use Only

Date received:

Accepted:

Proof of age attached:Yes No

Signed Rider:

Parent or Guardian if under 16 years old.

Please return this form to your club secretary. OO

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