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DECLARATION

I hereby declare that I understand the application and instructions and that the information provided by me in this application is true and correct to the best of my knowledge. Further I understand that to make false or misleading statements, either orally or in writing when applying for membership will result in denial of acceptance for membership with the Wentworth Shooting Sports Club.

Applicants Signature: ____________________________________   Date: __________

WAIVER FOR COLLECTION OF INFORMATION FROM OTHER THAN THE INDIVIDUAL CONCERNED

I _________________________________ hereby authorize and give permission to the Wentworth Shooting Sports Club to collect information concerning myself from the references given on my application inclusive of but not excluding academic records; medical, physical and or mental; employment history including disciplinary records; character and police contact information and criminal record data from sources other than myself in accordance to the MUNICIPAL FREEDOM OF INFORMATION AND PRIVACY ACT.

I further authorize the release of information to the Wentworth Shooting Sports Club by person(s) or organization(s) that may possess it.

This information is used solely for the purpose of accessing my suitability for consideration of membership with the Wentworth Shooting Sports Club.

Applicants Signature: _________________________________  Date: ____________

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