MBCSA Application form 2022

Membership Application Form 2023

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

CityProvince

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
prevnext( X )
1st Quarter: January - December 20231,050.00ZAR

2nd Quarter: April - December 2023950.00ZAR

3rd Quarter: July - December 2023750.00ZAR

4th Quarter: October - December 2023550.00ZAR

Re-application755.00ZAR

Optional: Nametag for family members150.00ZAR

Quantity

Optional: Indemnity cards for family members25.00ZAR

Quantity

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

Total 0.00ZAR
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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