Application form for Millennium 21 Computer Club
   
                                                                                     Confidential




Membership No:________________                Password*:___________________

Category:______________________               Entry date: _________


Title:              ______                                               
Last name:     _____________________             Driver Lic.No:_________________
First Name:    _____________________             PC model:____________________
Date of birth: _____________________              Serial No:_____________________
Phone/home: _____________________
Company:     ________________________________________________________
Business type: ____________________


ADDRESS:

Street:                 ________________________

Suburb:  ________________________     Postal code: __________

Please register me as a Club member of Millennium 21 Computer Club. I have read and understood the terms and conditions on the back of this application form and other documents that they  related to and I agree to abide by them. 

Signature:  _____________________         Witness:_______________________


Nominator Member/Agent Details

Name:      ______________________
Address:  _________________________________  Postcode: __________
Phone:     _________________