PATRIOTS AUSTRALIA Inc

Adelaide Chapter
Application for Membership

PLEASE NOTE
In order for you to become a FULL member of Patriots Australia, you must provide us with a copy of either your discharge certificate, or
record log. By accepting to join Patriots Australia, you agree to Patriots Australia contacting the Department of Defence to validate your
details if required. A member of the Chapter that you have selected, will contact you via the details provided in this form to complete the
application process, which will include serving a minimum of three (3) months nominee period, attend meetings & participate in organised
rides before being conferred as a Full or Associate Membership, whichever is applicable.

I agree to allowing Patriots Australia to contact the Department of Defence to validate my service history:

Surname: Given Names:

Preferred Nickname: DOB: Once completed go to File –

Attach to Email – and send it to:
Address: adelaidepatriots@iinet.net.au

Or maill to:

Daytime Phone: Mobile: The Secretary,

c/- Adelaide Chapter, Patriots
Email: Australia,
PO Box 2024. SALISBURY
DOWNS. SA. 5108.
Partner’s Preferred Name
Service Details

Service: Army Navy Air Force

Date of Enlistment: Date of Discharge:

Rank at Discharge: Reg No / PMKeys:

Proof of Service:
(A copy of which is to be attached to this application)

Type of Bike Ridden: CCs Rego No:

Recommended by: Seconded by:

…………..…………………………………for office use ………………………………………………….

Club Secretary:
Application Received: date: Nominee Patch Allocated: date:

Treasurer:
Fees Received: date: Full Member Status: date:

Member s Patriots Number: Associate Member Status date:

Created by Fester Created on 4/08/2008 4:34:00 PM