APEX SUPPLY HOUSE
PO Box 7084,
Urangan, HERVEY BAY, QLD 4655
PH: 07 4125 1349 FAX: 07
4125 2894
E-mail:
chris@ozsupplyhouse.com.au
Web site: apex.ozsupplyhouse.com.au
DINNER BADGE ORDER FORM
[Effective 1st April, 2007]
Contact
Name:____________________________________________ Club
Name:_______________________________________
Address:__________________________________________________________________________________________________
Phone: [W]__________________
[H]_____________________ [M]_______________________ FAX]_____________________
Email:
_____________________________________________________________________________________________________
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PLEASE PRINT NEATLY AS NO RESPONSIBILITY WILL BE TAKEN FOR
ILLEGIBLE WRITING
Please ensure
that your occupation is filled out if you require this on your
badge along with your name |
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Surname:__________________________________
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Surname:__________________________________ |
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Given Names:_______________________________
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Given Names:_______________________________
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Address:_________________________________
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Address:_________________________________
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_________________________________________ |
_________________________________________ |
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Phone:
[Work]_____________________________ |
Phone:
[Work]_____________________________ |
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[Home]____________________________
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[Home]____________________________ |
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[Mobile]____________________________
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[Mobile]____________________________ |
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[Fax]______________________________
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[Fax]______________________________ |
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Email:____________________________________ |
Email:____________________________________
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Date of Birth:________________________________
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Date of Birth:________________________________
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Date Joined Apex/Club:_______________________
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Date Joined Apex/Club:_______________________
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Occupation:_______________________________
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Occupation:_______________________________
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Member No: _______________________________ |
Member No: _______________________________
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[To
be completed by National Office] |
[To be completed by National Office] |
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Name on badge:_____________________________
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Name on badge:_____________________________
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Badge Style No:_____________________________
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Badge Style No:_____________________________
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Year:
/ |
Year:
/ |
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Spouse Name:______________________________
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Spouse Name:______________________________
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  Spouse Badge Style No:
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Spouse Badge Style No: |
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3105 |
Member |
$10.00 |
3120 |
Partners/Plastic |
$6.50 |
3310 |
Life Member |
$10.00 |
3210 |
Dist. Gov |
$10.00 |
Dist. Gov |
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3110 |
President |
$10.00 |
3125 |
Partners/Deluxe |
$8.80 |
3315 |
Life mem/Partner |
$8.30 |
3215 |
P.
Dist. Gov |
$10.00 |
P.
Dist. Gov |
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3115 |
Past President |
$10.00 |
3405 |
Children/Boys |
$6.50 |
3140 |
Past/ret.member |
$10.00 |
3130 |
Secretary |
$10.00 |
Secretary |
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3305 |
Senior Active |
$10.00 |
3410 |
Children/Girls |
$6.50 |
3205 |
State Board |
$10.00 |
3135 |
Treasurer |
$10.00 |
Treasurer |
State Board and Life Member
Badges are only available via State Secretary
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Required date for delivery:
_______
NB- Post
outside of QLD can take up to 10 working days.
Alternatively, express post can take 1 -4 days.
Please advise us
if you have any urgent delivery dates.
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Summary:
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Qty |
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@ $10.00 = |
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@ $8.30 = |
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@ $8.80 = |
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@ $6.50 = |
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= |
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