VIC Pre-registration Form

Enter information below to pre-register for your next visit to Shire of Wyndham - East Kimberley

Personal Details

First Name*
 
Last Name*
 
Date Of Birth*
Day
Month
Year
 
Employer/Company
Unit Number
Street Number*
 
Street Name*
Street Type*
 
Town/Suburb*
 
State (Select N/A if using an overseas address)*
 
Postcode*
 
Country
Phone (mobile)*
 
Phone (work)
Email*
 

Identification

Identification Type (eg. Driver's license, passport etc.)*
 
ID Number*
 
ID Expiry Date*
   
State/Country of Issue*

Visit Details

Visit Start Date*
   
Visit End Date*
   
Reason for Visit*
 

Escort Details (If Known)

Escort Name
Escort ASIC Number
Escort ASIC Expiry Date
 
Please note that you must present your identification when collecting your Visitor Card