GOLD COAST JAZZ & BLUES CLUB

Couples Membership Application

Note: For couples who share the same Email Address and/or the same Postal Address, just enter ‘As Above’ in the partner’s section boxes for this information. *** Annual Memberships now available ***

Your Email Address

Your First Name

Your Last Name

Your Date Of Birth

Your Phone (Mobile Preferred)

Your Postal Address

Your Post Code

Partner's Email Address

Partner's First Name

Partner's Last Name

Partner's Date Of Birth

Partner's Phone No

Partner's Postal Address

Partner's Post Code

Preferred Payment Method

Credit Card / Paypal Direct Bank Deposit At Jazz Club Show