Activity provided Frequency i.e. 10 Fee structure i.e. Uniform or Uniform or i.e. swimming, gym week pass, season, membership, equipment equipment fee (if membership, unlimited weekly or session description i.e. applicable) pilates cost Team shirt, yoga mat (if applicable) Note. If you provide more than three activities or programs please attach additional information when submitting this form. Bank details (provider to complete) Bank name: Account name : BSB number : Account number: Declaration I have authority to make this application on behalf of my organisation. We will invoice the local government for the cost of SilverSport applicant fees within 30 days of their first attendance. We understand that the SilverSport trial project will end on 30 June 2017 and all invoices must be submitted by 31 July 2017. We hereby authorise the local government to make payments by direct credit (EFT) into the above mentioned account. Signature: Date: Submit your completed form to the local governments as per below details Belmont Local Bag 379, Cloverdale WA 6985 Telephone 9477 7454
Activity provided i.e. swimming, gym membership, pilates Frequency i.e. 10 week pass, season, unlimited Fee structure i.e. membership, weekly or session cost Uniform or equipment description i.e. Team shirt, yoga mat (if applicable) Uniform or equipment fee (if applicable) Note. If you provide more than three activities or programs please attach additional information when submitting this form. Bank details (provider to complete) Bank name: Account name : BSB number : Account number: Declaration I have authority to make this application on behalf of my organisation. We will invoice the local government for the cost of SilverSport applicant fees within 30 days of their first attendance. We understand that the SilverSport trial project will end on 30 June 2017 and all invoices must be submitted by 31 July 2017. We hereby authorise the local government to make payments by direct credit (EFT) into the above mentioned account. Signature: Date: Submit your completed form to the local governments as per below details Belmont Local Bag 379, Cloverdale WA 6985 Telephone 9477 7454
silversport-provider-registration-form6d237dcc55b76ffab2a0ff0c00ce4282.docx