I HAVE BEEN TOLD I DESERVE
“A FULL LIFE THAT ISN’T JUST ABOUT FIGHTING FOR THINGS”

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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