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logoACTJCL Inc.
(ACT Junior Chess League)

                Membership Form
Surname: Address: State: Postcode: Home Phone: Email: Parent/Guardian1 Parent/Guardian2 Name: Contact Phone: Child 1 Name: School: Date of Birth : School Year: Child 2 Name: School: Date of Birth : School Year: Child 3 Name: School: Date of Birth : School Year: The annual fee is $15 Individual or $20 Family. Membership is from 1 January to 31 December. For membership commencing after 31 July the fee is $10 Individual or $15 Family. Please complete the form and forward together with a cheque made payable to: ACT Junior Chess League, P.O Box 1403, Belconnen,A.C.T, 2616 Note that if you are playing rated games, other than Junior Chess League, you must also be a member of the ACT Chess Association. Admin Only Year of Membership: Payment by Cash / Cheque Receipt No: Date: