Application for QEMSC Membership
Date .................................................
I ________________________________________________ apply for membership of the
Queensland Early Motorcycle Sports Club Incorporated. I agree to be bound by the rules of association and by-laws of the club, and to conduct myself in a correct and sportsmanlike manner at all times.
Address _______________________________________________________________________
_________________________________________ Postcode ____________________
Phone: ___________ _____ (home); _______________ (work); ___________________ ( mobile)
Email ____________________________________
Occupation ______________________________ Your signature _________________________
Main interest (“X” box): □ pre 1946 solos □pre 1963 solos □pre 1973 solos
□ pre 1983 solos □post 1982 solos
□sidecars □ regularity □official/helper
Your motorcycle(s) Make ____________________ Year _________ Capacity _________
Make ____________________ Year _________ Capacity _________
Make ____________________ Year _________ Capacity _________
Make ____________________ Year _________ Capacity _________
Include $35 annual subscription with this form (due 1 January each year)
Payment by (“X” box): □ Cash □Cheque □Direct Deposit
Account Name: Qld Early Motorcycle Sports Club BSB: 124001 Account: 104 193 61
If paying by Direct Deposit please include your full name as the reference, print out the direct deposit receipt & fax both pages to Glynn Leitch on 07 38862877.
If you require Glynn to validate your membership so that you can obtain an MA license please tick this box □
& Glynn will send an email to MQ.
Membership officer: Glynn Leitch, 55 Kent Street, Q, Kallangur, 4503
Mobile: 0412 401436 Email: membership@qemsc.com.au