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Co-op 100 registration form
Co-op 100 registration form
Member's Details
Do you have a member card number?
I have a card number
I don't have a card number
Card number on your application form (six digits)
Member's first name
Member's surname
Member's date of birth
Joint Member's Details (if joint application)
Joint Member's first name
Joint Member's surname
Joint Member's date of birth
Company or Partnership Details (if applicable)
Company Name
Company ABN
Residential Address (PO Box not acceptable)
Residential Address
Address Line 1
Suburb
State
- Select -
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Postal Address
Postal Address as above
Postal Address
Address Line 1
Suburb
State
- Select -
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Daytime Phone Number
Mobile Phone Number
Email Address
Membership Declaration (All applicants accept)
Would you like to receive information regarding upcoming sales, events and promotions?
I/we hereby apply to become a member of the Co-op 100 rewards program. I understand that on issue of my membership card I am eligible to earn rewards points from Hastings Co-op businesses*. I acknowledge and agree to the terms and conditions including terms dealing with the privacy of information, and any other terms and conditions as amended or issued from time to time. *Excluding Bolwarra Road Service Station, Port Macquarie and Enterprise Rent a Car.
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