Direct Debit Member Form - Couple Member 1 Title * Member 1 Name * First Name Last Name Member 1 year of birth * Member 1 Email * Member 1 Mobile Number * member 2 title * member 2 name * First Name Last Name Member 2 year of birth * member 2 email * Member 2 mobile number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What activities are you interested in? Radio players Art appreciation Gardening group Bolivia Book discussion Bushwalking Caravan group Choir Computer group Computer lessons Cycling Five Hundred (cards) Four-wheel drive Golf – 9 and 18 holes Internet lessons Orchestra Photography Pleasure fishing Par 3 golf Snooker / 8 ball Social group Table tennis Tap dancing and variety Tennis Train the brain Weekly walkers If another activity, please specify Do you wish to be contacted by a representative of the group? * Yes No How did you hear about Retire Active SA? From a Retire Active SA member or group Visited website Visited Facebook page or was sent the link Found a link on another website Saw advertising material If by another source, please specify Thank you! If you have have questions, please contact us. *Required
