NEW Membership Online Application If you are human, leave this field blank.New Membership Application Form1. Joining Fee Payment Joining Fee monies must be sent to the Club at the same day as the submission of your on-line application. New membership cannot be validated unless the Joining Fee monies are received into the Club’s bank account. If the application does not proceed the Club will reimburse the monies paid. 2. New Members Fees Option 1 Joining Fee ($5.00) 12 mths Membership Fee ($40.00) 12 mths Magazine (PDF) (Inculded) Total Monies to be sent ($45.00) Option 2 Joining Fee ($5.00) 12 mths Membership Fee ($40.00) 12 mths Buick magazine ($35.00) Total Monies to be sent ($80.00) The Club year runs from 1st July to 30th June and members joining during the year will be eligible for a rebate on their membership renewal in the next year. The Club holds Public Liability Insurance to the value of $10 million. Payment details are set out in Item 5 below. 3. New Membership Information RequiredSurname *Given Name *Spouse / Partner *Address *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeHome PhoneMobile (preferred)Email (preferred)Date *4. Buicks Owned:(Ownership is not a prerequisite for membership.) First VehicleYearModelBody StyleChassis NoEngine NoRego NoConditionAwaiting RestorationUnder RestorationFully RestoredOriginalParts Car OnlySecond VehicleYearModelBody StyleChassis NoEngine NoRego NoConditionAwaiting RestorationUnder RestorationFully RestoredOriginalParts Car OnlyThird VehicleYearModelBody StyleChassis NoEngine NoRego NoConditionAwaiting RestorationUnder RestorationFully RestoredOriginalParts Car OnlyForth VehicleYearModelBody StyleChassis NoEngine NoRego NoConditionAwaiting RestorationUnder RestorationFully RestoredOriginalParts Car OnlyHow did you hear about the Buick car Club?Ad in Car journal/magazineExisting Member (who?)Attending Car ShowOtherDetails5. Payment(a) For On-Line membership applications, Joining Fee monies must be electronically sent via Direct Debit to the Club’s Bank Account: Bank: Heritage Bank Acct Name: Buick Car Club of Aust. Inc (QLD) BSB: 638070 Acct No. 8428328 (b) Please include your “Surname” with your Direct Debit: Membership OptionsPlease Choose one belowMember + PDF copy Magazine $45.00Member + Printed copy Magazine $80.00Indicate how you intend to pay fees.6. Agree to Join I do hereby make formal application to join the Buick Car Club of Australia Inc. (QLD) Electronic submission of this application is regarded as signing. Please fill in the Anti-Spam check below & then click SUBMIT Captcha *For security verification, please enter any random two digit number. For example: 36Submit