EmailMe Form - Magpie Army Registration Form

Name *

First Last

Email *

Cell Phone *

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Address if a shipment is required.

Cost: $100

Note: Shipment
: $5.00 (National)
: $15.00 (International)

All benefits of membership to the Magpie Army will become available once payment is received

SOUTHERN RUGBY FOOTBALL CLUB INC

Bank Account Number: 06 0901 0042080 00
Reference: "YOUR NAME" & army