[Please print & complete form & forward to address below]

MEMBERSHIP APPLICATION

Membership Fee:                       $25.00

NAME: Surname……………………First Name…………………Middle Name…………………

Title……….(Mr, Mrs, Ms)    Sex…………….(Male/Female)   Date Of Birth…………………..

ADDRESS:……………………………………………………………………………………………

………………………………………………………………POSTCODE…………………………..

Q Squash Affiliation number (if known)……………………………

(If not affiliated own insurance should be taken out)

Phone: (Home)……………………………..(Work)………………………………

             (Mobile)……………………………. (E-mail)……………………………..

Club…………………………………………Grade………………Position………………………..

Do you wish to receive your newsletter via email        Yes………… No……………

I, the undersigned, hereby make application for admission as a Member of the Queensland

Masters Squash Association Inc.

If accepted, I agree to abide by the rules and regulations set down by the Association.

Signature……………………………………………..Date…………………………….

PLEASE REMIT THIS APPLICATION TOGETHER WITH PAYMENT OF $25.00 TO:

(CHEQUES PAYABLE TO QMSA)

Mrs Ada Lanham

Treasurer, QMSA

59 Rennie Street

INDOOROOPILLY QLD 4068