PONTIAN CLUB CANBERRA NEW MEMBER REGISTRATION FORM
Please complete the form and click submit below.
A confirmation will be e-mailed to you to confirm your registration.
Required Fields*
Please Select A Membership Type *  
 
Single
Family
Contact Details  
Title
First Name *
Surname *
Licence Number *
Date Of Birth *
E-Mail *
Daytime Phone
Mobile
Street Address
Suburb
State
Post Code
*
I certify that the above information is true and correct
 
Please fill in the Required Items marked with a *