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: