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Name(Required)

First Last

Mobile(Required)

Email(Required)

Address(Required)

Date of Birth(Required)

Sex(Required)

Male

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Direct Debit Fortnite

Paid in Full for 12 Months

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BSB

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Expiry Month

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I acknowledge that by signing this Agreement I have received and read the Club Membership and Liability Release Agreement and agree to be bound by all the terms and conditions of this Agreement in their entireties for the duration of my membership.

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