MBCSA Application form 2022

Membership Application Form 2022

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
prev next ( X )
1st Quarter: January - March 2022 1,000.00 ZAR

2nd Quarter: April - June 2022 900.00 ZAR

3rd Quarter: July - September 2022 700.00 ZAR

4th Quarter: October - December 2022 500.00 ZAR

Re-application 755.00 ZAR

Optional: Nametag for family members 150.00 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:

Now create your own Jotform - It's free! Create your own Jotform