LBRCA MEMBERSHIP APPLICATION FORM Please enable JavaScript in your browser to complete this form.CONTACT DETAILSCompany Name *ABN *Name *Contact Position *Address *City *State *NSWACTQLDVICNTSAWATASPost Code *Phone *Email *LBRCA Member Updates will be sent to the email address listed above, along with up to two additional email addresses. Please provide these below.Please tick this box if you do not wish to receive the LBRCA Member Update.Email 1Email 2Type 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-contractorDriverAssociateRetiredSUPPLIER INFORMATIONAs an LBRCA member, you can access exclusive sponsor benefits. Provide your account details below or tick the boxes to receive more information. Note: LBRCA will contact sponsors (excluding NTI) directly to link your membership to the benefit/s. To access benefits from NTI, please provide your membership number to your insurance broker.bp AustraliaMiddle 8 digits of cardDon't have a bp Australia account but would like to know more?No, not interestedYes, send more infoNTI Policy No.Don't have a NTI policy but would like to know more?No, not interestedYes, send more infoRepco Commercial Account No.Don't have a Repco Commercial account but would like to know more?No, not interestedYes, send more infoLowes Account No.Don't have a Lowes account but would like to know more?No, not interestedYes, send more infoAmpol Account No.Don't have an Ampol account but would like to know more?No, not interestedYes, send more infoShell Card Account No.Don't have a Shell Card but would like to know more?No, not interestedYes, send more infoMobil Account No.Don't have a Mobil account but would like to know more?No, not interestedYes, send more infoRiordan Fuels Account No.Don't have a Riordan Fuels account but would like to know more?No, not interestedYes, send more infoBy providing my account numbers as part of this membership application, I hereby give my express consent to the Livestock, Bulk and Rural Carriers Association (LBRCA) to contact my relevant sponsor organisation and link my accounts to the applicable LBRCA member discount and rebate programs. I acknowledge and agree that, where my accounts are linked to LBRCA arrangements, any existing discounts, rebates or benefits I may have with those sponsors or other third parties may be altered, replaced or no longer apply. I confirm that I have the authority to provide these account details.Who is your truck supplier?Who is your engine supplier?What are the top three issues concerning you or impacting on your business now?List any priority access constraints you have now.How did you hear about the LBRCA?Privacy PolicyPlease tick this box if you do not consent to your personal information being collected, used and disclosed by LBRCA in accordance with the privacy policy.Your privacy is our priority. The information you provide will be used to process your application for LBRCA membership and to deliver your member benefits. By signing this form, you acknowledge that you have read the LBRCA Privacy Policy, available at www.lbrca.org.au, and consent to your personal information being collected, used and disclosed by LBRCA for the purposes outlined in that policy. You have the right not to provide your personal information.MEMBERSHIP FEES(inc. GST) Membership fees are calculated per truck. For operators with a fleet of 10+ please contact the Secretariat on 0432 336 718. Small RigidFee: $148.50012345678910Truck & DogFee: $275.00012345678910Prime Mover & TrailerFee: $275.00012345678910Driver/Non-Industry ActiveFee: $126.50012345678910AssociateFee: $950.00012345678910RetiredFee: $55.00012345678910Total Amount (inc. GST)$0.00Credit Card *CardName on CardPhoneSUBMIT
