– Mark E. Smith

Date 20040928 Name PLEASE PRINT Joe Clark Full Residential Address PLEASE PRINT Toronto Signature Joe Clark Please Select the Appropriate Category Below MEMBER’S GUEST ☐ I declare that I will remain in the reasonable company of the member at all times & will not remain on club premises any longer than the member Members Signature Member No TEMPORARY MEMBER ☑ I declare that I reside outside a 5km radius of this club OR am a member of another registered club with similar objects to those of this club Club Name Member No BONDI ICEBERGS CLUB Bondi Icebergs Club Co-Op Ltd. 1 Notts Avenue, Bondi NSW 2026 Telephone: 9130 3120 Facsimile: 9130 7174 • I declare that I have attained the age of 18 and if required shall show identification, details of which may be recorded. • All Temporary Members and Member’s guests must adhere to the directions of the management of the club and also the club’s house policy on responsible service of alcohol and gaming. • All visitors and guests must assume the conse-quences of entering into club premises where smoking is permitted. • Only visitors who are members of RECIPROCAL CLUBS may purchase takeaway liquor. • This slip must be carried whilst on Club premises and shown on request or when claiming poker machine payouts. • This slip is valid only for day of issue only. 134216

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