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Application - New Graduate Transfer Promo

Membership Number *

First Name *

Last Name *

Date of Birth *

Telephone Number *

Would you like to continue your Membership? *

Yes

Club Account and Signing Privileges Request

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.

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

Settlement Details

Please nominate your preferred payment method. *

Direct Debit from a nominated bank account

Credit or Debit Card

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.

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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