Are you attending this event?

Yes No Maybe

Basic details

First name*

Last name*

Phone number*

Email address*

Address*

Member club:*

Fraser Coast

Western Stars

Suncoast

Allstars

Buderim

Rosemore

River City

Helensvale

I confirm that I am an authorised officer of the member club listed above and that I am lodging this proxy on behalf of the club*

Yes

No-Only an authorised officer of the member club can nominate a proxy.

Position in club*

I appoint the following person as proxy*

Proxy contact details* Max 255 characters

Specific voting instructions (If any) Max 255 characters

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.