Wallaby Friends Buddies Membership
On-line Registration Form
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Any unauthorized copying in-part or as a whole is strictly prohibited.
(Please Note: All minor children, must have parent permission before filling in this form.)
(Please Note: * Means Required Field.)
Primary Card Holders Info.
Your Buddies Card Holders Info.
*Full Name:
*Full Name:
(Note: Please fill in name as it appears on your D.L. or Govt. Carried I.D.)
(Note: Please fill in buddies name as it appears on D.L. or Govt. Carried I.D.)
*Mailing Address:
Mailing Address:
(Note: This is were you want cards to be shipped to. Billing address will be asked for in final payment.)
*State / Providence:
State / Providence:
*Zip Code:
Zip Code:
*Date of Birth:
*Date of Birth:
(Example: M: 00 / D: 00 / Y: 00)         
*Last 4 of D.L. or
Govt. Carried I.D. #:
*Last 4 of D.L. or
Govt. Carried I.D. #:
(Example: X X X 1 2 3 4)
*E-mail Address:
E-mail Address:
If you received one of our promotion cards, please enter your code below.
If no promotion code, please enter 0000's.
Promotion Code