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:_______________________________ |
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]____________________________ |
[Home]____________________________ |
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[Mobile]____________________________ |
[Mobile]____________________________ |
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[Fax]______________________________ |
[Fax]______________________________ |
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Email:____________________________________ |
Email:____________________________________
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Date
of Birth:________________________________ |
Date
of Birth:________________________________ |
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Date
Joined Apex/Club:_______________________ |
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:_____________________________ |
Name
on badge:_____________________________ |
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Badge
Style No:_____________________________ |
Badge
Style No:_____________________________ |
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Year:
/ |
Year:
/
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Spouse
Name:______________________________ |
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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@
$ = |
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@
$ = |
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Postage |
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= |
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ORDINARY MAIL $3.50 (badges) SMALL EXPRESS $9.00
(badges) LARGE EXPRESS $12.75 (badges and kits)
Please email sales@supplyhouse.net.au or phone
0741251349 if unsure which postage applies to your
order
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