To become a member of Escape Club all you have to do is complete this online application form - no fee, no charges, just the opportunity to earn free nights and other benefits when you stay at participating Constellation Hotels. Please note: This form is for New Zealand residents only, click here to sign up as an Australian resident Personal Details: Name:* Title First Name Surname Dr Mr Mrs Miss Ms ---------- DOB: - Day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - Month - January February March April May June July August September October November December - Year - 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 Do you smoke? Yes No Occupation:* - Occupation - Accounting / Finance Consulting Customer Service / Support Education / Training Engineering Executive / Senior Management General Admin / Supervisory Government / Public Sector Health / Medical Home Maker Information Technology Manufacturing Primary Producers Research Retired Sales & Marketing Travel ----------------------------------------------------------------- Address:**       Suburb Postcode Email:* Home Phone:* Mobile Number: Club Reference: Business Details: Business Name: Address:        Suburb  Postcode Business Phone: Business Fax: Interests: Travel mostly for:* - Travel type - Business Holiday Visiting Friends ---------------------------------- Hotel Nights:* - Visit Period - 1-2 stays per annum 1-3 nights per month 4-8 nights per month 9 nights per month ---Holiday Options--- weekend / short break 5+ nights 7+ nights ---------------------------------- Most travelled to :* ----------ACT----------- Greenway ---New South Wales---- Albury Armidale Bathurst Coffs Harbour Coonabarabran Cootamundra Cowra Diamond Beach Dubbo Raymond Terrace Moama Moree Orange Parkes Penrith Port Macquarie Tamworth Terrigal Tumut Wagga Wagga Wentworth Yass ------Queensland------- Brisbane Bundaberg Cairns Gin Gin Gladstone Goondawindi Ipswich Mackay Noosaville Rockhampton Surfers Paradise -----South Australia----- Adelaide Clare Valley -------Tasmania-------- Launceston -------Victoria-------- Bendigo Bright Echuca Geelong Horsham Mildura Shepparton Warrnambool ---Western Australia---- Belmont Perth ------New Zealand------ Auckland Christchurch Dunedin Hokitika Invercargill Napier Nelson Rotorua Wanganui --------------------- Other How did you hear about The Escape Club? - please select - Hotel Staff Hotel Directory / Brochure Constellation Hotels website Country Comfort Website Australis Website Chifley Website Constellation Hotels website Press Advertising Direct Mail / Email Central Reservations If other please specify in box below If not on the list above, please specify below I agree to be contacted by phone: Business Home I would like to receive news and offers via email I would be prepared to participate in market research I have read and agree to abide by the Terms and Conditions Please note: * signifies a mandatory field. ** Address must be current as it's where your card package will be sent Our Privacy Statement explains in general terms how Constellation Hotel Group protects the privacy of your personal information under the National Privacy Principles. It will apply to any personal information you provide to us: Privacy Statement