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The Traralgon Greyhound's Rovers Roulette Form

Personal Information

Name

Address

Phone Number

Email Address

Number and Payment Selection

Number Preference (Please provide 5 numbers between 1 - 50)

Payment Frequency

Payment Method

Credit Card Information

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Card Type

Name on Card

Card Number

Expiry Date (MM/YYYY)

CCV

I authorize Traralgon Rovers CC to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account

Signature

Signature

Date

First Direct Debit Payment 01/10/2026 - Last Direct Debit Payment 18/03/2027
Bank Deposit Details:
Account Name: Traralgon Rovers Cricket Club Inc
BSB: 633 000
Account Number: 113374532
* If you win while on Direct Debit payment, a portion of the winnings will be used to pay the remainder owing