MBCSA Application form 2020

Membership Application Form 2020

New Member Details:
Initials & Surname *
Name *
ID Number *
Occupation *
Membership Number
For re-applications only.
Postal Address *

City Province

Postal Code
Cell Number *
E-mail *
Spouse

Children: Name & DOB

Name

Date of Birth

#1

#2

#3

#4

#5

Vehicles:

Year

Colour

Model

Series

Vin

#1

#2

#3

#4

#5

Membership Fees:

Including 1 x Name Tag & Indemnity Card
Initial Registration Fees
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1st Quarter: January - March 2019 875.00 ZAR

2nd Quarter: April - June 2019 775.00 ZAR

3rd Quarter: July - September 2019 625.00 ZAR

4th Quarter: October - December 2019 425.00 ZAR

Re-application 725.00 ZAR

Optional: Nametag for family members 100.00 ZAR

Quantity

Optional: Indemnity cards for family members 25.00 ZAR

Quantity

Gift Pack : 1 x Grill badge; 1 x Key ring; 1 x Lapel pin 675.00 ZAR

Total 0.00 ZAR
Declaration
Banking Details:

STANDARD BANK - BRAKPAN

ACCOUNT NO: 020939442

BANK CODE: 01-20-42

Email proof of bank deposit to membership@mercedesbenzclub.co.za

New membership applications will be processed on Wednesday mornings between 09h00 - 12h00!
Special Requests:
Should be Empty:

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