South East Metro Region (Home of the South East Seagulls)

Level 0 - Intro2 Cricket Registration Form

Region 15

Intro2 Cricket Registration Form 2009

Name:______________________________________________________________________________

Email Address:______________________________________________________________________

Mailing Address:____________________________________________________________________________

Postcode:_____________________ Date of Birth:________________________

Club:_______________________________________________________________________________

Please select your preferred venue:

East Malvern (Wednesday 28th October 7pm to 10pm):

Ormond (Wednesday 4th November 7pm to 10pm):

PAYMENT EITHER BY CHEQUE OR PLEASE COMPLETE THE FOLLOWING PAYMENT OPTION:

Please ensure you attach your $10 payment and forward back to Sam Symes a week before the selected Course.
Payment can be made by cheque (please ensure it is made out to Cricket Victoria).

We also accept the following credit cards:

Bankcard: Mastercard: Visa: Diners: American Express:

Card No:

Expiry Date: …………/20…….

Card Holder’s Name: …………………………………………………………………………..

Signature: ………………….………………………………………..……………..

Upon receipt of payment, this document will be a Tax Invoice for GST purposes, please keep a copy for your records

Please return the completed registration to Cricket Victoria either by fax to (03) 9653 1185 or by mail to the address below.
If you have any queries please call Sam Symes on 0413 888 402 or email ssymes@cricketvictoria.com.au

Please Note: Registrations close a week prior to the course

Cricket Victoria, 86 Jolimont Street, Jolimont, Vic., 3002
Tel: 03 9653 1100 w Fax: 03 9653 1185

Level 0 - Intro2 Cricket Registration Form

Region 15

Intro2 Cricket Registration Form 2009

Please return the completed registration to Cricket Victoria either by fax to (03) 9653 1185 or by mail to the address below.

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