APEX SUPPLY HOUSE

 

PO Box 7084, Urangan, HERVEY BAY, QLD 4655

 

PH:  07 4125 1059   FAX:  07 4125 2894   E-mail:  brenda@ozsouvenirs.net,au

Web site:  apexsupplyhouse.com.au

 

DINNER BADGE ORDER FORM  [Effective 1st April, 2014]

 

Contact Name:____________________________________________ Club Name:_______________________________________

 

Address:__________________________________________________________________________________________________

 

Phone: [W]__________________    [H]_____________________    [M]_______________________ FAX]_____________________

 

Email: _____________________________________________________________________________________________________

 

 

 

 

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

 

 

 

 

 

 

 

Surname:__________________________________

 

Surname:__________________________________

 

 

Given Names:_______________________________

Given Names:_______________________________

 

 

Address:_________________________________

 

Address:_________________________________

_________________________________________

_________________________________________

 

 

Phone:    [Work]_____________________________

Phone:    [Work]_____________________________

              [Home]____________________________

               [Home]____________________________

              [Mobile]____________________________

               [Mobile]____________________________

              [Fax]______________________________

               [Fax]______________________________

Email:____________________________________

Email:____________________________________

 

 

Date of Birth:________________________________

Date of Birth:________________________________

 

 

Date Joined Apex/Club:_______________________

Date Joined Apex/Club:_______________________

 

 

Occupation:_______________________________

Occupation:_______________________________

 

 

Member No:  _______________________________

Member No:  _______________________________

                    [To be completed by National Office]

                      [To be completed by National Office]

 

 

Name on badge:_____________________________

Name on badge:_____________________________

 

 

Badge Style No:_____________________________

Badge Style No:_____________________________

 

 

Year:                                        /

Year:                                        /              

 

Spouse Name:______________________________

Spouse Name:______________________________

 

 

Spouse Badge Style No:

Spouse Badge Style No:

 

3105

Member

$10.00

3120

Partners/Plastic

$6.50

3310

Life Member

$10.00

3210

Dist. Gov

$10.00

Dist. Gov

3110

President

$10.00

3125

Partners/Deluxe

$8.80

3315

Life mem/Partner

$8.30

3215

P. Dist. Gov

$10.00

P. Dist. Gov

3115

Past President

$10.00

3405

Children/Boys

$6.50

3140

Past/ret.member

$10.00

3130

Secretary

$10.00

Secretary

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

 

 

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.

 

 

 

Summary:

 

Qty

 

@ $10.00 =

 

 

 

@ $          =

 

 

 

@ $          =

 

 

Postage

@             =

 

 

 

               =

 

 

 

ORDINARY MAIL $4.00 (badges) SMALL EXPRESS $11.00 (badges up to 500gms) LARGE EXPRESS $15.80 

Please email  brenda@ozsouvenirs.net.au or phone 07 41251059 if unsure which postage applies to your order

Most Popular