Membership Application Form


Personal Details


Title                           Mr /  Miss  /  Ms  /  Mrs (please circle)             Other (please list)   ______________________       

First Name               ____________________________                 Preferred Name      ______________________

Surname                  ____________________________

Email                         _________________________________________________________________________

Mobile                     ____________________________                 Home Phone          ______________________


Gender                    Male              Female                                          Date of Birth             ____/___/_____     


Home Address

Street Address        ________________________                          Suburb          ___________________________

State                         ________________________                          Postcode      ___________________________


Mailing Address

Tick if mailing address is same as home address

Mailing Address      ________________________                          Suburb          ___________________________

State                         ________________________                          Postcode      ___________________________


The Registered Clubs Act requires that ALL of the above details must be provided where possible.

Failure to provide all of the requested information may result in your application being rejected.


o        1 Year Membership                                $  8.00                     o  1 Year Pensioner Membership        $  3.50


o        3 Year Membership                                $  15.00                   o  3 Year Pensioner Membership        $  7.00



o   5 Year Ordinary Membership                 $  32.00                   o  5 Year Pensioner Membership        $ 14.00


           Must provide your aged or disability pension card to receive pensioner membership


Declarations and Consent

1. I am over the age of 18 years and wish to become a member of Parkes Services & Citizens’ Club Co-Operative Limited (Parkes Services Club) and request that you enter my name on the Register of Members accordingly. If duly elected to the club, I hereby agree to abide by the Memorandum and Articles of Association, Rules, House Policy, By- Laws and Policies of the Parkes Services & Citizens Club Co-operative Ltd.

2.           I consent to receiving marketing materials, advertising and other offer materials from Parkes Services Club including but not limited to material relating to birthday               rewards, prize draws, promotions, entertainment, food, beverage, gaming and Parkes Services Club rewards program.

3. I understand that membership is not transferable and the fee, or any part there of is not refundable.

4. All club members over 18 years are entitle to participate in Parkes Services Club rewards program. I agree that my participation in the Parkes Services Club reward program is subject to the Parkes Services Club Rewards Terms and Conditions (as amended from time to time).



Signature of Applicant   ___________________                     Date              ___/___/_____


Privacy Act

You have a right to access and correct any of your personal information that the club holds about you.

The Parkes Services Club is subject to the provisions of the Privacy Act 1988. The personal information provided by you on this application will be used to process your membership application.

The club does not usually disclose our personal information to any other organisation or person unless there is a legal requirement to do so. The club may disclose your information to third parties that provide services under contract to the club. These contracts require the third party to keep your personal information confidential and secure.


Your personal information, including information about you obtained as a result of you placing your membership card in a club machine (not ATMs), may be used by the club for marketing purposes to improve our services and to provide you with the latest information about those services and any new related services and promotions





Member No: ______________   Amount Paid $__________________             Date ______________________        


Identification Check       Drivers Licence         Passport         Proof of Age Card          ID No:   _________________



Pension Check             Aged                  Disability   Card no. ____________    ID Expiry Date:_________________



Staff Signature _____________________


Player Activity Statements are available on request. THINK ABOUT YOUR CHOICES.