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Family Nominee Membership

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Application - Family Nominee Membership

This section is for the main (or Primary) members details

Title *

First Name *

Surname *

Primary Member Number - If Known

Only complete if the Primary Member is a current University Club Member. Family Memberships are required to have a full fee-paying Member appointed as the Primary Member.

Applicant's Relationship to Primary Member *

Family nominees must be direct family members of the Primary Member. IMPORTANT: Due to licensing restrictions, individuals who are under the age of 18, and those who are currently enrolled in Undergraduate study at The University of Western Australia are unable to join the University Club.

Applicant Details

Are you a Current University Club Member? *

Yes- Please provide your Membership number and Name below then continue with the application.

No - Please proceed below with this application.

Member Number (Only complete if you are a current Club Member)

Title *

First Name *

Last Name *

Preferred Name

Date of Birth *

Street Address *

City (Suburb) *

State *

Postcode *

Country *

Email *

Telephone Number *

Postal Address (if applicable)

City (Suburb)

State

Postcode

Country

Club Account Request

Members with valid payment details on file are able to charge incidental expenditures such as food and beverage purchases and member events to their Member accounts *

Yes, I would like a Club Account

No, I would not like a Club Account

The Club provides signing privileges through a credit facility for all Members allowing charging food, beverage and event expenditure to their Club account. To set up a Club Account, it is mandatory that Members provide the Club with details of a nominated credit card or transaction account from which these charges can be debited. If you choose to pay your subscription by credit card or direct debit then this account will also be used for payment of incidental charges. Settlement of incidental expenditure is by direct transfer from a nominated credit card or transaction account on or around the 20th of each calendar month. A statement of account will be issued to you in the first week of each calendar month for any membership subscription and incidental charges.

Settlement Details

Membership subscription fees are paid monthly by automatic direct debit

Please provide your preferred payment method. We do not capture card or bank information on form. We will reach out to you to confirm card details in person.

Please nominate your preferred payment method.

Direct Debit from a nominated bank account

Credit or Debit Card

Ezidebit account payment Terms and Conditions - Click Here To View

I authorise Ezidebit Pty Ltd ACN 096 902 813 (User ID 342190, 428198) (“Ezidebit”) to debit payments from my account, at intervals and amounts by The University Club of Western Australia Pty Ltd (“The Business”)as per the Terms and Conditions of my agreement with the Business and in accordance with this Direct Debit Request and the DDR Service Agreement. *

Declaration - Terms and Conditions - Click Here To View

I have read and understand the Terms and Conditions of Membership and the information provided on this form and agree that acceptance of the Membership application implies that I accept the By-Laws and Regulations of The University Club. I also fully understand that the Membership Sub-Committee reserves the right to approve or reject my application without assigning any reasons whatsoever. *

Consent - Code of Conduct - Click Here To View

I have read and agree to The University Club of Western Australia Member's Code of Conduct as set out in the link above. *

Full Name *

Date *

Thank you! We look forward to welcoming you to the Club as a Member

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