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Application - Leave of Absence reinstatement

Membership Number *

First Name *

Last Name *

Date of Birth *

Telephone Number *

Would you like to continue your Membership? *

Yes

We appreciate you taking the time to review the below information.

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: *

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