LBRCA MEMBERSHIP APPLICATION FORM Please enable JavaScript in your browser to complete this form.CONTACT DETAILSName *FirstLastCompany Name *ABN *Email *WebsitePhone *MobileAddress *City *State *NSWACTQLDVICNTSAWATASPost Code *Type of Operation (Select all that apply) *LivestockBulk (Hay/Grain)WoolFuelWaterFertiliserHeavy HaulageConstructionForestryMiningTowingWasteOtherIf Other, please specifyClassification of Operation *Large Road Freight CompanyMedium Road Freight CompanySmall Road Freight CompanyOwner/OperatorSub-contractorDriverN/ASupplier InformationAs an LBRCA member, you are eligible to receive exclusive benefits from our Blue-Ribbon, National, and other major sponsors (from time-to-time). If you have existing accounts/policies with these suppliers, please provide your relevant fleet and account numbers below. Or, if you are interested in receiving more information about the offers from these companies, please tick the relevant boxes.BP AustraliaMiddle 8 digits of cardDon't have an account but would like to know more?No, not interestedYes, send more infoNTI Policy No.Don't have an account but would like to know more?No, not interestedYes, send more infoRepco Commercial Account No.Don't have an account but would like to know more?No, not interestedYes, send more infoLowes Account No.Don't have an account but would like to know more?No, not interestedYes, send more infoAmpol Account No.Don't have an account but would like to know more?No, not interestedYes, send more infoWho is your truck supplier?Who is your engine supplier?Have you purchased a ICEPACK in the past 12 months?YesNoIf yes, list the serial number/s here:What are the top two issues concerning you or impacting on your business now?List any priority access constraints you have now.How did you hear about the LBRCA?What is your shirt size?How would you like to receive the Weekly Newsletter? *EmailFaxPrivacy Policy: Your privacy is our priority. All information you have provided will help us process your application to become an LBRCA member and obtain all benefits from your membership, including benefits provided through our affiliation with the Australian Livestock and Rural Transporters Association (ALRTA). By signing this form, you acknowledge that you have read the LBRCA Privacy Policy, a full copy of which can be found at www.lbrca.org.au. You consent to the personal information contained in this form and any other personal information you provide either the LBRCA and the ALRTA being collected, used and disclosed by the LBRCA and the ALRTA for the purposes and in the ways set out in the privacy policy. You have a right not to provide your personal information. You have a right not to provide your personal information to our affiliated body the ALRTA.Please tick this box if you do not consent to your personal information being collected, used and disclosed by the LBRCA and the ALRTA for the purposes and ways set out in the privacy policy.MEMBERSHIP FEESexc. GSTSmall Rigid - $135 inc. GSTSelect Quantity0 - $ 0.001 - $ 135.002 - $ 270.003 - $ 405.004 - $ 540.005 - $ 675.00Truck & Dog - $250 inc. GSTSelect Quantity0 - $ 0.001 - $ 250.002 - $ 500.003 - $ 750.004 - $ 1,000.005 - $ 1,250.00Prime Mover & Trailer - $250 inc. GSTSelect Quantity0 - $ 0.001 - $ 250.002 - $ 500.003 - $ 750.004 - $ 1,000.005 - $ 1,250.00Driver/Non-Industry Active - $115 inc. GSTSelect Quantity0 - $ 0.001 - $ 115.002 - $ 230.003 - $ 345.004 - $ 460.005 - $ 575.00Retired - $50 inc. GSTSelect Quantity0 - $ 0.001 - $ 50.002 - $ 100.003 - $ 150.004 - $ 200.005 - $ 250.00Total Amount (inc. GST)$ 0.00Credit Card *CardName on CardNameSUBMIT
